1
|
de la Plaza Llamas R, Ortega Azor L, Hernández Yuste M, Gorini L, Latorre-Fragua RA, Díaz Candelas DA, Al Shwely Abduljabar F, Gemio del Rey IA. Quality-adjusted life years and surgical waiting list: Systematic review of the literature. World J Gastrointest Surg 2024; 16:1155-1164. [PMID: 38690041 PMCID: PMC11056653 DOI: 10.4240/wjgs.v16.i4.1155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/26/2024] [Accepted: 02/25/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND The quality-adjusted life year (QALY) is a metric that is increasingly used today in the field of health economics to evaluate the value of different medical treatments and procedures. Surgical waiting lists (SWLs) represent a pressing problem in public healthcare. The QALY measure has rarely been used in the context of surgery. It would be interesting to know how many QALYs are lost by patients on SWLs. AIM To investigate the relationship between QALYs and SWLs in a systematic review of the scientific literature. METHODS The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. An unlimited search was carried out in PubMed, updated on January 19, 2024. Data on the following variables were investigated and analyzed: Specialty, country of study, procedure under study, scale used to measure QALYs, the use of a theoretical or real-life model, objectives of the study and items measured, the economic value assigned to the QALY in the country in question, and the results and conclusions published. RESULTS Forty-eight articles were selected for the study. No data were found regarding QALYs lost on SWLs. The specialties in which QALYs were studied the most in relation to the waiting list were urology and general surgery, with 15 articles each. The country in which the most studies of QALYs were carried out was the United States (n = 21), followed by the United Kingdom (n = 9) and Canada (n = 7). The most studied procedure was organ transplantation (n = 39), including 15 kidney, 14 liver, 5 heart, 4 lung, and 1 intestinal. Arthroplasty (n = 4), cataract surgery (n = 2), bariatric surgery (n = 1), mosaicplasty (n = 1), and septoplasty (n = 1) completed the surgical interventions included. Thirty-nine of the models used were theoretical (the most frequently applied being the Markov model, n = 34), and nine were real-life. The survey used to measure quality of life in 11 articles was the European Quality of Life-5 dimensions, but in 32 articles the survey was not specified. The willingness-to-pay per QALY gained ranged from $100000 in the United States to €20000 in Spain. CONCLUSION The relationship between QALYs and SWLs has only rarely been studied in the literature. The rate of QALYs lost on SWLs has not been determined. Future research is warranted to address this issue.
Collapse
Affiliation(s)
- Roberto de la Plaza Llamas
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Lorena Ortega Azor
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Marina Hernández Yuste
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Ludovica Gorini
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
| | - Raquel Aránzazu Latorre-Fragua
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | | | - Farah Al Shwely Abduljabar
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Ignacio Antonio Gemio del Rey
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| |
Collapse
|
2
|
Meregaglia M, Nicod E, Drummond M. The estimation of health state utility values in rare diseases: do the approaches in submissions for NICE technology appraisals reflect the existing literature? A scoping review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:1151-1216. [PMID: 36335234 PMCID: PMC10406664 DOI: 10.1007/s10198-022-01541-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 10/11/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Rare diseases negatively impact patients' quality of life, but the estimation of health state utility values (HSUVs) in research studies and cost-utility models for health technology assessment is challenging. OBJECTIVES This study compared the methods for estimating the HSUVs included in manufacturers' submissions of orphan drugs to the National Institute for Health and Care Excellence (NICE) with those of published studies addressing the same rare diseases to understand whether manufacturers fully exploited the existing literature in developing their economic models. METHODS All NICE Technology Appraisal (TA) and Highly Specialized Technologies (HST) guidance documents of non-cancer European Medicines Agency (EMA) orphan medicinal products were reviewed and compared with any published primary studies, retrieved via PubMed until November 2020, and estimating HSUVs for the same conditions addressed in manufacturers' submissions. RESULTS We identified 22 NICE TA/HST appraisal reports addressing 19 different rare diseases. Sixteen reports presented original HSUVs estimated using EQ-5D or Health Utility Index (n = 12), direct methods (n = 2) or mapping (n = 2), while the other six included values obtained from the literature only. In parallel, we identified 111 published studies: 86.6% used preference-based measures (mainly EQ-5D, 60.7%), 12.5% direct techniques, and 2.7% mapping. The collection of values from non-patient populations (using 'vignettes') was more frequent in manufacturers' submissions than in the literature (22.7% vs. 8.0%). CONCLUSIONS The agreement on methodological choices between manufacturers' submissions and published literature was only partial. More efforts should be made by manufacturers to accurately reflect the academic literature and its methodological recommendations in orphan drugs submissions.
Collapse
Affiliation(s)
- Michela Meregaglia
- Research Centre on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Milan, Italy.
| | - Elena Nicod
- Research Centre on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Milan, Italy
| | | |
Collapse
|
3
|
Leonardis F, Gitto L, Favi E, Oliva A, Angelico R, Mitterhofer A, Cacciola I, Santoro D, Manzia TM, Tisone G, Cacciola R. A Keynesian perspective on the health economics of kidney transplantation would strengthen the value of the whole organ donation and transplantation service. Front Public Health 2023; 11:1120210. [PMID: 37050945 PMCID: PMC10083402 DOI: 10.3389/fpubh.2023.1120210] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/27/2023] [Indexed: 03/29/2023] Open
Abstract
BackgroundIn this study, the Keynesian principle “savings may be used as investments in resources” is applied to Kidney Transplantation (KT), contextualizing the whole Organs Donation and Transplantation (ODT) service as a unique healthcare entity. Our aim was to define the financial resources that may be acquired in the form of savings from the KT activity.MethodsWe analyzed registry and funding data for ODT in our region, between 2015 and 2019. Our hypotheses aimed to evaluate whether the savings would offset the Organ Donation (OD) costs, define the scope for growth, and estimate what savings could be generated by higher KT activity. To facilitate the evaluation of the resources produced by KT, we defined a coefficient generated from the combination of clinical outcomes, activity, and costs.ResultsThe ODT activity reached a peak in 2017, declining through 2018–2019. The savings matured in 2019 from the KT activity exceeded €15 million while the OD costs were less than €9 million. The regional KT activity was superior to the national average but inferior to international benchmarks. The estimated higher KT activity would produce savings between €16 and 20 million.ConclusionThe financial resources produced by KT contribute to defining a comprehensive perspective of ODT finance. The optimization of the funding process may lead to the financial self-sufficiency of the ODT service. The reproducible coefficient allows a reliable estimate of savings, subsequently enabling adequate investments and budgeting. Applying such a perspective jointly with reliable estimates would establish the basis for an in-hospital fee-for-value funding methodology for ODT.
Collapse
Affiliation(s)
- Francesca Leonardis
- UTV Intensive Care Unit, Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Lara Gitto
- Dipartimento di Economia, Università degli Studi di Messina, Messina, Italy
| | - Evaldo Favi
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- *Correspondence: Evaldo Favi,
| | - Angelo Oliva
- Coordinamento Trapianti, Policlinico Tor Vergata, Rome, Italy
| | - Roberta Angelico
- Department of Surgical Sciences, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | | | - Irene Cacciola
- Department of Clinical and Experimental Medicine, Medicine and Hepatology Unit, University Hospital of Messina, Messina, Italy
| | - Domenico Santoro
- Dipartimento di Medicina Clinica e Sperimentale, UOC di Nefrologia e Dialisi, Università degli Studi di Messina, Messina, Italy
| | - Tommaso Maria Manzia
- Department of Surgical Sciences, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Giuseppe Tisone
- Department of Surgical Sciences, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Roberto Cacciola
- UTV Intensive Care Unit, Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Department of Surgical Sciences, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| |
Collapse
|
4
|
Nikl A, Janssen MF, Brodszky V, Rencz F. A head-to-head comparison of the EQ-5D-5L and 15D descriptive systems and index values in a general population sample. Health Qual Life Outcomes 2023; 21:17. [PMID: 36803866 PMCID: PMC9940337 DOI: 10.1186/s12955-023-02096-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/03/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND The EQ-5D-5L and 15D are generic preference-accompanied health status measures with similar dimensions. In this study, we aim to compare the measurement properties of the EQ-5D-5L and 15D descriptive systems and index values in a general population sample. METHODS In August 2021, an online cross-sectional survey was conducted in a representative adult general population sample (n = 1887). The EQ-5D-5L and 15D descriptive systems and index values were compared in terms of ceiling and floor, informativity (Shannon's Evenness index), agreement, convergent and known-groups validity for 41 chronic physical and mental health conditions. Danish value sets were used to compute index values for both instruments. As a sensitivity analysis, index values were also estimated using the Hungarian EQ-5D-5L and Norwegian 15D value sets. RESULTS Overall, 270 (8.6%) and 1030 (3.4*10-6%) unique profiles occurred on the EQ-5D-5L and 15D. The EQ-5D-5L dimensions (0.51-0.70) demonstrated better informativity than those of 15D (0.44-0.69). EQ-5D-5L and 15D dimensions capturing similar areas of health showed moderate or strong correlations (0.558-0.690). The vision, hearing, eating, speech, excretion and mental function 15D dimensions demonstrated very weak or weak correlations with all EQ-5D-5L dimensions, which may indicate potential room for EQ-5D-5L bolt-ons. The 15D index values showed lower ceiling than the EQ-5D-5L (21% vs. 36%). The mean index values were 0.86 for the Danish EQ-5D-5L, 0.87 for the Hungarian EQ-5D-5L, 0.91 for the Danish 15D and 0.81 for the Norwegian 15D. Strong correlations were found between the index values (Danish EQ-5D-5L vs. Danish 15D 0.671, Hungarian EQ-5D-5L vs. Norwegian 15D 0.638). Both instruments were able to discriminate between all chronic condition groups with moderate or large effect sizes (Danish EQ-5D-5L 0.688-3.810, Hungarian EQ-5D-5L 1.233-4.360, Danish 15D 0.623-3.018 and Norwegian 15D 1.064-3.816). Compared to the 15D, effect sizes were larger for the EQ-5D-5L in 88-93% of chronic condition groups. CONCLUSIONS This is the first study to compare the measurement properties of the EQ-5D-5L and 15D in a general population sample. Despite having 10 fewer dimensions, the EQ-5D-5L performed better than the 15D in many aspects. Our findings help to understand the differences between generic preference-accompanied measures and support resource allocation decisions.
Collapse
Affiliation(s)
- Anna Nikl
- Department of Health Policy, Corvinus University of Budapest, 8 Fővám tér, Budapest, 1093, Hungary
- Károly Rácz Doctoral School of Clinical Medicine, Semmelweis University, Budapest, Hungary
| | - Mathieu F Janssen
- Section Medical Psychology and Psychotherapy, Department of Psychiatry, Erasmus MC, Rotterdam, The Netherlands
| | - Valentin Brodszky
- Department of Health Policy, Corvinus University of Budapest, 8 Fővám tér, Budapest, 1093, Hungary
| | - Fanni Rencz
- Department of Health Policy, Corvinus University of Budapest, 8 Fővám tér, Budapest, 1093, Hungary.
| |
Collapse
|
5
|
Frasco PE, Mathur AK, Chang YH, Alvord JM, Poterack KA, Khurmi N, Bauer I, Aqel B. Days alive and out of hospital after liver transplant: comparing a patient-centered outcome between recipients of grafts from donation after circulatory and brain deaths. Am J Transplant 2023; 23:55-63. [PMID: 36695622 DOI: 10.1016/j.ajt.2022.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 01/13/2023]
Abstract
We retrospectively compared outcomes between recipients of donation after circulatory death (DCD) and donation after brain death (DBD) liver allografts using days alive and out of hospital (DAOH), a composite outcome of mortality, morbidity, and burden of care from patient perspective. The initial length of stay and duration of any subsequent readmission for the first year after liver transplantation were recorded. Donor category and perioperative and intraoperative characteristics pertinent to liver transplantation were included. The primary outcome was DAOH365. Secondary outcomes included early allograft dysfunction and hepatic arterial and biliary complications. Although the incidence of both early allograft dysfunction (P < .001) and ischemic cholangiopathy (P < .001) was significantly greater in the recipients of DCD, there were no significant differences in the length of stay and DAOH365. The median DAOH365 was 355 days for recipients of DBD allografts and 353 days for recipients of DCD allografts (P = .34). Increased transfusion burden, longer cold ischemic time, and non-White recipients were associated with decreased DAOH. There were no significant differences in graft failure (P = .67), retransplantation (P = .67), or 1-year mortality (P = .96) between the 2 groups. DAOH is a practical and attainable measure of outcome after liver transplantation. This metric should be considered for quality measurement and reporting in liver transplantation.
Collapse
Affiliation(s)
- Peter E Frasco
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA.
| | - Amit K Mathur
- Department of Transplantation Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Yu-Hui Chang
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jeremy M Alvord
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Karl A Poterack
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Narjeet Khurmi
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Isabel Bauer
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Bashar Aqel
- Department of Transplant Hepatology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| |
Collapse
|
6
|
Krüger M, Samsom RA, Oosterhoff LA, van Wolferen ME, Kooistra HS, Geijsen N, Penning LC, Kock LM, Sainz-Arnal P, Baptista PM, Spee B. High level of polarized engraftment of porcine intrahepatic cholangiocyte organoids in decellularized liver scaffolds. J Cell Mol Med 2022; 26:4949-4958. [PMID: 36017767 PMCID: PMC9549510 DOI: 10.1111/jcmm.17510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 05/30/2022] [Accepted: 07/23/2022] [Indexed: 12/01/2022] Open
Abstract
In Europe alone, each year 5500 people require a life-saving liver transplantation, but 18% die before receiving one due to the shortage of donor organs. Whole organ engineering, utilizing decellularized liver scaffolds repopulated with autologous cells, is an attractive alternative to increase the pool of available organs for transplantation. The development of this technology is hampered by a lack of a suitable large-animal model representative of the human physiology and a reliable and continuous cell source. We have generated porcine intrahepatic cholangiocyte organoids from adult stem cells and demonstrate that these cultures remained stable over multiple passages whilst retaining the ability to differentiate into hepatocyte- and cholangiocyte-like cells. Recellularization onto porcine scaffolds was efficient and the organoids homogeneously differentiated, even showing polarization. Our porcine intrahepatic cholangiocyte system, combined with porcine liver scaffold paves the way for developing whole liver engineering in a relevant large-animal model.
Collapse
Affiliation(s)
- Melanie Krüger
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Roos-Anne Samsom
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Loes A Oosterhoff
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Monique E van Wolferen
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Hans S Kooistra
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Niels Geijsen
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Louis C Penning
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Linda M Kock
- LifeTec Group BV, Eindhoven, The Netherlands.,Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Pilar Sainz-Arnal
- Laboratory of Organ Bioengineering and Regenerative Medicine, Health Research Institute of Aragon (IIS Aragon), Zaragoza, Spain
| | - Pedro M Baptista
- Laboratory of Organ Bioengineering and Regenerative Medicine, Health Research Institute of Aragon (IIS Aragon), Zaragoza, Spain
| | - Bart Spee
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
7
|
Lee H, Jang S, Ahn SH, Kim BK. Cost-effectiveness of antiviral therapy in untreated compensated cirrhosis patient with serum HBV-DNA level < 2000 IU/mL. Hepatol Int 2022; 16:294-305. [PMID: 35322374 DOI: 10.1007/s12072-022-10310-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/28/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Due to stringent reimbursement criteria, significant numbers of patients with compensated cirrhosis (CC) and low-level viremia [LLV; serum hepatitis B virus (HBV)-DNA levels of 20-2000 IU/mL] remain untreated especially in the East Asian countries, despite potential risk of disease progression. We analyzed cost-effectiveness to assess rationales for antiviral therapy (AVT) for this population. METHODS We compared cost and effectiveness (quality-adjusted life years, QALYs) in a virtual cohort including 10,000 54-year-old CC-LLV patients receiving AVT (Scenario I) versus no treatment (Scenario II). A Markov model, including seven HBV-related conditions, was used. Values for transition probabilities and costs were mostly obtained from recent real-world South Korean data. RESULTS As per a simulation of a base-case analysis, AVT reduced costs by $639 USD and yielded 0.108 QALYs per patient for 5 years among CC-LLV patients compared to no treatment. Thus, AVT is a cost-saving option with lower costs and better effectiveness than no treatment. If 10,000 patients received AVT, 815 incident cases of hepatocellular carcinoma (HCC) and 630 HBV-related deaths could be averted in 5 years compared to no treatment. In case of 10-year observation, AVT was consistently dominant. Even when the transition probabilities from CC-LLV vs. maintained virological response to HCC were same, fluctuation of results also lied within willingness-to-pay in South Korea. In the probabilistic sensitivity analysis with the willingness-to-pay threshold, the probability of AVT cost-effectiveness was 100%. CONCLUSION The extended application of AVT in CC-LLV patients may contribute positively to individual clinical benefits and national healthcare budgets.
Collapse
Affiliation(s)
- Hankil Lee
- College of Pharmacy, Ajou University, Suwon, Gyeonggi-do, Republic of Korea
| | - Sungin Jang
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Yonsei Liver Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Yonsei Liver Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.
| |
Collapse
|
8
|
Webb AN, Lester ELW, Shapiro AMJ, Eurich DT, Bigam DL. Cost-utility analysis of normothermic machine perfusion compared to static cold storage in liver transplantation in the Canadian setting. Am J Transplant 2022; 22:541-551. [PMID: 34379887 DOI: 10.1111/ajt.16797] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 01/25/2023]
Abstract
To estimate the incremental cost-effectiveness of a liver transplant program that utilizes normothermic machine perfusion (NMP) alongside static cold storage (SCS) compared to SCS alone (control). A Markov model compared strategies (NMP vs. control) using 1-year cycle lengths over a 5-year time horizon from the public healthcare payer perspective. Primary micro-costing data from a single center retrospective trial were applied along with utility values from literature sources. Transition probabilities were deduced using the retrospective trial cohort, local transplant data, and supplemented with literature values. Scenario and probabilistic sensitivity analysis (PSA) were conducted. The NMP strategy was cost-effective in comparison to the control strategy, which was dominated. The mean cost for NMP was $456 455 (2021 US$) and the control was $519 222. The NMP strategy had greater incremental quality-adjusted life years (QALYs) gains over 5 years compared to the control, with 3.48 versus 3.17, respectively. The overarching results remained unchanged in scenario analysis. In PSA, NMP was cost-effective in 63% of iterations at a willingness-to-pay threshold of $40 941. The addition of NMP to a liver transplant program results in greater QALY gains and is cost-effective from the public healthcare payer perspective.
Collapse
Affiliation(s)
- Alexandria N Webb
- Department of Surgery, University of Alberta, Edmonton, AB, Canada.,School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Erica L W Lester
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | | | - Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - David L Bigam
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
9
|
Rustgi VK, Duff SB, Elsaid MI. Cost-effectiveness and potential value of pharmaceutical treatment of nonalcoholic fatty liver disease. J Med Econ 2022; 25:347-355. [PMID: 35034553 DOI: 10.1080/13696998.2022.2026702] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is associated with substantial morbidity, mortality, and economic burden. With currently no approved treatment, an effective pharmaceutical intervention for this disease must be both clinically- and cost-effective. METHODS A Markov model was constructed to estimate the clinical outcomes, costs, and quality of life impact of a hypothetical pharmaceutical intervention. Lifetime clinical outcomes, life-years, quality-adjusted life-years (QALYs), costs (2020 $US), incremental cost-effectiveness ratios (ICERs), and economically justifiable prices (EJPs) were quantified. Only patients with fibrosis stage F2-F4 were assumed eligible to initiate pharmaceutical treatment. RESULTS Over a mean life expectancy of approximately 21 years in the simulated cohort, drug treatment reduced liver-related mortality by 6.0% (2.7% absolute reduction). Assuming an annual drug cost of $36,000, total discounted medical costs were $574,238 and $120,312 for drug and usual care, respectively, with discounted QALYs estimated to be 9.452 and 9.272 for the two comparators. This yielded an ICER of $2,517,676/QALY gained. The EJP of the drug at an ICER threshold of $150,000/QALY gained was $2,633, a 93% reduction from a base case. Sensitivity analyses suggest that, without a substantial decrease in the drug price, ICERs would exceed $500,000/QALY gained even with the most favorable efficacy assumptions. CONCLUSIONS For a pharmaceutical intervention to be considered cost-effective in the NAFLD fibrosis population, the substantial clinical benefit will need to be coupled with a modest annual price. Annual drug costs exceeding $12,000 likely will not provide reasonable value, even with favorable efficacy. More work is needed to estimate the cost-effectiveness of lifestyle modifications.
Collapse
Affiliation(s)
- Vinod K Rustgi
- Department of Medicine, Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Steve B Duff
- Veritas Health Economics Consulting, Inc, Carlsbad, CA, USA
| | - Mohamed I Elsaid
- Department of Medicine, Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
10
|
Lee H, Kim BK, Jang S, Ahn SH. Cost-Effectiveness Analysis of Antiviral Therapy for Untreated Minimally Active Chronic Hepatitis B to Prevent Liver Disease Progression. Clin Transl Gastroenterol 2021; 12:e00299. [PMID: 33600103 PMCID: PMC7889372 DOI: 10.14309/ctg.0000000000000299] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/07/2020] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Antiviral therapy (AVT) for chronic hepatitis B (CHB) can prevent liver disease progression. Because of its stringent reimbursement criteria, significant numbers of patients with untreated minimally active (UMA)-CHB exist, although they are still subject to disease progression. We thus performed a cost-effectiveness analysis to assess the rationale for AVT for UMA-CHB. METHODS We compared cost and effectiveness (quality-adjusted life years, QALYs) in virtual UMA-CHB cohorts of 10,000 50-year-olds receiving AVT (scenario 1) vs no treatment (scenario 2) for 10 years. A Markov model, including 7 health states of CHB-related disease progression, was used. Values for transition probabilities and costs were mostly obtained from recent South Korean data. RESULTS The simulation of AVT vs no treatment predicted $2,201 incremental costs and 0.175 incremental QALYs per patient for 10 years, with an incremental cost-effectiveness ratio (ICER) of $12,607/QALY, suggesting cost-effectiveness of AVT. In sum, if 10,000 patients received AVT, 720 incident hepatocellular carcinoma and 465 CHB-related more deaths could be averted in 10 years relative to no treatment. When the simulated analysis period was extended to 20 years, AVT was also highly cost-effective with an ICER of $2,036/QALY. Although hepatocellular carcinoma-related mortality was a major factor influencing ICER, its fluctuation can be accepted within willingness to pay of $33,000 in South Korea. According to probabilistic sensitivity analysis with the threshold of willingness to pay, the probability of AVT cost-effectiveness was 83.3%. DISCUSSION Long-term AVT for patients with UMA-CHB may contribute positively toward individual clinical benefit and national health care budget.
Collapse
Affiliation(s)
- Hankil Lee
- Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Yonsei Liver Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Sungin Jang
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Yonsei Liver Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| |
Collapse
|
11
|
Carcedo Rodriguez D, Artola Urain T, Chinea Rodriguez A, García Torres E, González Vicent M, Gutiérrez García G, Regueiro García A, Calvo Hidalgo M, Villacampa A. Cost-effectiveness analysis of defibrotide in the treatment of patients with severe veno-occlusive disease/sinusoidal obstructive syndrome with multiorgan dysfunction following hematopoietic cell transplantation in Spain. J Med Econ 2021; 24:628-636. [PMID: 33858278 DOI: 10.1080/13696998.2021.1916749] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIMS This study evaluated cost-effectiveness of defibrotide vs best supportive care (BSC) for the treatment of hepatic veno-occlusive disease/sinusoidal obstructive syndrome (VOD/SOS) with multiorgan dysfunction (MOD) post-hematopoietic cell transplantation (HCT) in Spain. MATERIALS AND METHODS A two-phase Markov model, comprising a 1-year acute phase with daily cycles and a lifetime long-term phase with annual cycles, was adapted to the Spanish setting. The model included a cohort of patients with severe VOD/SOS (defined as VOD/SOS with MOD) post-HCT. For the acute phase, efficacy and VOD/SOS-related length of stay were obtained from a phase 3 defibrotide study (NCT00358501). VOD/SOS-related hospital stays were 7.5 and 23.2 days in defibrotide-treated and BSC patients, respectively. Defibrotide-treated patients spent 30% of their stay in the intensive care unit vs 60% in BSC patients. Assumptions for the long-term phase and utility values were obtained from the literature. Costs were from the Spanish Health System perspective (€2019). Defibrotide cost was based on 25 mg/kg/day over 17.5 days, using local expert opinion. Life-years (LYs), quality-adjusted LYs (QALYs), and costs were estimated over a lifetime horizon, applying a 3% discount rate for costs and outcomes. Sensitivity analyses assessed the robustness of the results. RESULTS Defibrotide produced an additional 1.214 QALYs and 1.348 LYs vs BSC, with a total cost of €33,708 more than BSC alone. However, defibrotide resulted in savings up to €16,644/patient for cost of hospital stay. Difference between costs and effective measures led to ratios of €27,757/QALY and €25,007/LY gained. Additional hospital stays had the greatest influence on base-case results. Probabilistic analysis confirmed the robustness of the deterministic results. LIMITATIONS Limitations include use of historical controls and assumptions extrapolated from the literature. CONCLUSIONS This cost-effectiveness model, adapted to the Spanish setting, showed that defibrotide is a cost-effective alternative to BSC alone in patients with severe VOD/SOS post-HCT.
Collapse
Affiliation(s)
| | | | | | | | | | - Gonzalo Gutiérrez García
- Bone Marrow Transplant Unit - Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | | | | | | |
Collapse
|
12
|
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.
Collapse
|
13
|
Neuberger J. Follow-up of liver transplant recipients. Best Pract Res Clin Gastroenterol 2020; 46-47:101682. [PMID: 33158465 PMCID: PMC7485448 DOI: 10.1016/j.bpg.2020.101682] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/31/2020] [Accepted: 09/03/2020] [Indexed: 01/31/2023]
Abstract
The number of surviving liver allograft recipients is increasing almost exponentially. The quality and length of life is increasing but most recipients have reduced survival and quality of life compared with healthy matched individuals. Causes of premature death include cardio and cerebrovascular disease, renal failure, graft failure, de novo malignancy and recurrent disease. Follow-up is needed lifelong to ensure graft and patient health and ensure that complications are recognised and treated early. Immunosuppression is kept to the appropriate minimum and prophylactic interventions are given early, such as use of statins and tight control of blood pressure and blood sugar. Recipients will require life-long follow-up, and this is placing an increasing burden on transplant units. Follow-up is best done by close collaboration between the Liver Transplant Unit, the local hospital and primary care team. Involvement of other health care practitioners, such as recipient coordinators, pharmacists, dermatologists and addiction specialists may improve outcomes. Key to successful follow-up are agreed protocols and good communication between the recipients and all relevant health care providers. Use of IT allows for better communication and will support use of video and telephone consultations in selected instances. The most appropriate follow-up will depend on many factors, including logistic and geographic issues, local experience. The provision of well-funded and supported registries at local, national and international levels will allow for improvements in management.
Collapse
|
14
|
The Use of Donation After Circulatory Death Organs for Simultaneous Liver-kidney Transplant: To DCD or Not to DCD? Transplantation 2019; 103:1159-1167. [DOI: 10.1097/tp.0000000000002434] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Estes C, Anstee QM, Arias-Loste MT, Bantel H, Bellentani S, Caballeria J, Colombo M, Craxi A, Crespo J, Day CP, Eguchi Y, Geier A, Kondili LA, Kroy DC, Lazarus JV, Loomba R, Manns MP, Marchesini G, Nakajima A, Negro F, Petta S, Ratziu V, Romero-Gomez M, Sanyal A, Schattenberg JM, Tacke F, Tanaka J, Trautwein C, Wei L, Zeuzem S, Razavi H. Modeling NAFLD disease burden in China, France, Germany, Italy, Japan, Spain, United Kingdom, and United States for the period 2016-2030. J Hepatol 2018; 69:896-904. [PMID: 29886156 DOI: 10.1016/j.jhep.2018.05.036] [Citation(s) in RCA: 1070] [Impact Index Per Article: 178.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 05/07/2018] [Accepted: 05/23/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are increasingly a cause of cirrhosis and hepatocellular carcinoma globally. This burden is expected to increase as epidemics of obesity, diabetes and metabolic syndrome continue to grow. The goal of this analysis was to use a Markov model to forecast NAFLD disease burden using currently available data. METHODS A model was used to estimate NAFLD and NASH disease progression in eight countries based on data for adult prevalence of obesity and type 2 diabetes mellitus (DM). Published estimates and expert consensus were used to build and validate the model projections. RESULTS If obesity and DM level off in the future, we project a modest growth in total NAFLD cases (0-30%), between 2016-2030, with the highest growth in China as a result of urbanization and the lowest growth in Japan as a result of a shrinking population. However, at the same time, NASH prevalence will increase 15-56%, while liver mortality and advanced liver disease will more than double as a result of an aging/increasing population. CONCLUSIONS NAFLD and NASH represent a large and growing public health problem and efforts to understand this epidemic and to mitigate the disease burden are needed. If obesity and DM continue to increase at current and historical rates, both NAFLD and NASH prevalence are expected to increase. Since both are reversible, public health campaigns to increase awareness and diagnosis, and to promote diet and exercise can help manage the growth in future disease burden. LAY SUMMARY Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis can lead to advanced liver disease. Both conditions are becoming increasingly prevalent as the epidemics of obesity and diabetes continue to increase. A mathematical model was built to understand how the disease burden associated with non-alcoholic fatty liver disease and non-alcoholic steatohepatitis will change over time. Results suggest increasing cases of advanced liver disease and liver-related mortality in the coming years.
Collapse
Affiliation(s)
- Chris Estes
- Center for Disease Analysis (CDA), Lafayette, CO, USA
| | - Quentin M Anstee
- Liver Research Group, Institute of Cellular Medicine, The Medical School, Newcastle University, Framlington Place, Newcastle-upon-Tyne, United Kingdom
| | - Maria Teresa Arias-Loste
- Gastroenterology and Hepatology Department, Marqués de Valdecilla University Hospital, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Santander, Spain; Infection, Immunity and Digestive Pathology Group, Research Institute Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Heike Bantel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Stefano Bellentani
- Gastroenterology and Hepatology Service, Clinica Santa Chiara, Locarno, Switzerland
| | - Joan Caballeria
- Hepatology Unit, Hospital Clinic, Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red: Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Massimo Colombo
- Center for Translational Research in Hepatology, Clinical and Research Center Humanitas, Rozzano, Italy
| | - Antonio Craxi
- Department of Gastroenterology, University of Palermo, Palermo, Italy
| | - Javier Crespo
- Gastroenterology and Hepatology Department, Infection, Immunity and Digestive Pathology Group, IDIVAL, Instituto de Investigación Valdecilla, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Christopher P Day
- Liver Research Group, Institute of Cellular Medicine, The Medical School, Newcastle University, Framlington Place, Newcastle-upon-Tyne, United Kingdom
| | - Yuichiro Eguchi
- Liver Center, Saga University Hospital, Saga University, Saga, Japan
| | - Andreas Geier
- Division of Hepatology, Department of Medicine II, University of Würzburg, Würzburg, Germany
| | - Loreta A Kondili
- Center for Global Health, Istituto Superiore di Sanita, Rome, Italy
| | - Daniela C Kroy
- Department of Medicine III, RWTH University Hospital Aachen, Aachen, Germany
| | - Jeffrey V Lazarus
- ISGlobal, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Rohit Loomba
- NAFLD Research Center, Department of Medicine, University of California San Diego, La Jolla, CA, USA; Division of Gastroenterology, Department of Medicine, University of California at San Diego, La Jolla, CA, USA
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Giulio Marchesini
- Unit of Metabolic Diseases and Clinical Dietetics, DIMEC, "Alma Mater" University, Bologna, Italy
| | - Atsushi Nakajima
- Division of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Francesco Negro
- Divisions of Gastroenterology and Hepatology and of Clinical Pathology, University Hospital, rue Gabrielle-Perret-Gentil 4, 1211 Genève 14, Switzerland
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, Di.Bi.M.I.S., University of Palermo, Italy
| | - Vlad Ratziu
- Department of Hepatology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France; University Pierre et Marie Curie, Institut National de la Santé et de la Recherche Médicale UMR 938, Paris, France
| | - Manuel Romero-Gomez
- Unit for the Clinical Management of Digestive Diseases & CIBERehd, Virgen del Rocio University Hospital, Seville, Spain
| | - Arun Sanyal
- Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Jörn M Schattenberg
- Department of Medicine I, University Medical Centre, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Frank Tacke
- Department of Medicine III, RWTH University Hospital Aachen, Aachen, Germany
| | - Junko Tanaka
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Christian Trautwein
- Department of Medicine III, RWTH University Hospital Aachen, Aachen, Germany
| | - Lai Wei
- Peking University People's Hospital, Peking University Hepatology Institute, Beijing, China; Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, Beijing, China
| | | | - Homie Razavi
- Center for Disease Analysis (CDA), Lafayette, CO, USA.
| |
Collapse
|
18
|
Vascularized Thymosternal Composite Tissue Allo- and Xenotransplantation in Nonhuman Primates: Initial Experience. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 5:e1538. [PMID: 29632759 PMCID: PMC5889452 DOI: 10.1097/gox.0000000000001538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/29/2017] [Indexed: 01/07/2023]
Abstract
Background: Vascularized composite allotransplantation is constrained by complications associated with standard immunosuppressive strategies. Vascularized thymus and bone marrow have been shown to promote prolonged graft survival in composite organ and soft-tissue vascularized composite allotransplantation models. We report development of a nonhuman primate vascularized thymosternal composite tissue transplant model as a platform to address donor-specific immune tolerance induction strategies. Methods: Vascularized thymosternal allograft (skin, muscle, thymus, sternal bone) was transplanted between MHC-mismatched rhesus monkeys (feasibility studies) and baboons (long-term survival studies), with end-to-side anastomoses of the donor aorta and SVC to the recipient common femoral vessels. A male allograft was transplanted to a female’s lower abdominal wall, and clinically applicable immunosuppression was given. Skin biopsies and immunological assays were completed at regular intervals, and chimerism was quantified using polymerase chain reaction specific for baboon Y chromosome. Results: Four allo- and 2 xenotransplants were performed, demonstrating consistent technical feasibility. In 1 baboon thymosternal allograft recipient treated with anti-CD40–based immunosuppression, loss of peripheral blood microchimerism after day 5 was observed and anticipated graft rejection at 13 days. In the second allograft, when cutaneous erythema and ecchymosis with allograft swelling was treated with anti-thymocyte globulin starting on day 6, microchimerism persisted until immunosuppression was reduced after the first month, and the allograft survived to 87 days, 1 month after cessation of immunosuppression treatment. Conclusions: We established both allo- and xeno- composite vascularized thymosternal transplant preclinical models, which will be useful to investigate the role of primarily vascularized donor bone marrow and thymus.
Collapse
|
19
|
McLaren ZM, Sharp A, Hessburg JP, Sarvestani AS, Parker E, Akazili J, Johnson TRB, Sienko KH. Cost effectiveness of medical devices to diagnose pre-eclampsia in low-resource settings. DEVELOPMENT ENGINEERING 2017; 2:99-106. [PMID: 29276756 PMCID: PMC5737708 DOI: 10.1016/j.deveng.2017.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Maternal mortality remains a major health challenge facing developing countries, with pre-eclampsia accounting for up to 17 percent of maternal deaths. Diagnosis requires skilled health providers and devices that are appropriate for low-resource settings. This study presents the first cost-effectiveness analysis of multiple medical devices used to diagnose pre-eclampsia in low- and middle-income countries (LMICs). METHODS Blood pressure and proteinuria measurement devices, identified from compendia for LMICs, were included. We developed a decision tree framework to assess the cost-effectiveness of each device using parameter values that reflect the general standard of care based on a survey of relevant literature and expert opinion. We examined the sensitivity of our results using one-way and second-order probabilistic multivariate analyses. RESULTS Because the disability-adjusted life years (DALYs) averted for each device were very similar, the results were influenced by the per-use cost ranking. The most cost-effective device combination was a semi-automatic blood pressure measurement device and visually read urine strip test with the lowest combined per-use cost of $0.2004 and an incremental cost effectiveness ratio of $93.6 per DALY gained relative to a baseline with no access to diagnostic devices. When access to treatment is limited, it is more cost-effective to improve access to treatment than to increase testing rates or diagnostic device sensitivity. CONCLUSIONS Our findings were not sensitive to changes in device sensitivity, however they were sensitive to changes in the testing rate and treatment rate. Furthermore, our results suggest that simple devices are more cost-effective than complex devices. The results underscore the desirability of two design features for LMICs: ease of use and accuracy without calibration. Our findings have important implications for policy makers, health economists, health care providers and engineers.
Collapse
Affiliation(s)
- Zoë M McLaren
- Health Management and Policy, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
| | - Alana Sharp
- Health Management and Policy, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
| | - John P Hessburg
- Department of Biomedical Engineering, College of Engineering, University of Michigan, 2350 Hayward St., 1109 GG Brown, Ann Arbor, MI 48109-2125USA
| | - Amir Sabet Sarvestani
- Design Science Program, College of Engineering, University of Michigan, 2350 Hayward St., 1109 GG Brown, Ann Arbor, MI 48109-2125, USA
| | - Ethan Parker
- Health Management and Policy, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
| | - James Akazili
- Navrongo Health Research Centre, Navrongo, Upper East, Ghana
| | - Timothy R B Johnson
- Department of Obstetrics & Gynecology, Medical School, University of Michigan, L4000 Womens SPC 5276, Ann Arbor, MI 48109-5276, USA
| | - Kathleen H Sienko
- Departments of Mechanical and Biomedical Engineering, College of Engineering, University of Michigan, 2350 Hayward St., 3454 GG Brown, Ann Arbor, MI 48109-2125, USA
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
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
| |
Collapse
|
22
|
Onghena L, Develtere W, Poppe C, Geerts A, Troisi R, Vanlander A, Berrevoet F, Rogiers X, Van Vlierberghe H, Verhelst X. Quality of life after liver transplantation: State of the art. World J Hepatol 2016; 8:749-756. [PMID: 27366301 PMCID: PMC4921796 DOI: 10.4254/wjh.v8.i18.749] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 05/04/2016] [Accepted: 06/03/2016] [Indexed: 02/06/2023] Open
Abstract
Quality of life (QoL) after deceased donor liver transplantation is increasingly recognized as a major outcome parameter. We reviewed recent publications in this rapidly evolving field in order to summarize recent achievements in the field and to define opportunities and perspectives for research and improvement of patient care. QoL does improve after liver transplantation according to a typical pattern. During the first year, there is a significant improvement in QoL. After one year, the improvement does stabilise and tends to decline slightly. In addition to the physical condition, different psychological parameters (such as depression, anxiety, sexual function) and sociodemographic elements (professional state, sex, marital state) seem to impact QoL. Opportunities for further research are the use of dedicated questionnaires and identification of influencing factors for QoL.
Collapse
|
23
|
Abstract
BACKGROUND The availability of donor organs limits the number of patients in need who are offered liver transplantation. Measures to expand the donor pool are crucial to prevent on-list mortality. The aim of this study was to evaluate the use of livers from deceased donors who were older than 75 years. METHODS Fifty-four patients who received a first liver transplant (D75 group) from 2001 to 2011 were included. Donor and recipient data were collected from the Nordic Liver Transplant Registry and medical records. The outcome was compared with a control group of 54 patients who received a liver graft from donors aged 20 to 49 years (D20-49 group). Median donor age was 77 years (range, 75-86 years) in the D75 group and 41 years (range, 20-49 years) in the D20-49 group. Median recipient age was 59 years (range, 31-73 years) in the D75 group and 58 years (range, 31-74 years) in the D20-49 group. RESULTS The 1-, 3-, and 5-year patient/graft survival values were 87/87%, 81/81%, and 71/67% for the D75 group and 88/87%, 75/73%, and 75/73% for the D20-49 group, respectively. Patient (P = 0.89) and graft (P = 0.79) survival did not differ between groups. The frequency of biliary complications was higher in the D75 group (29.6/13%, P = 0.03). CONCLUSIONS Selected livers from donors over age 75 years should not be excluded based on age, which does not compromise patient or graft survival despite a higher frequency of biliary complications.
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
Zhang E, Wartelle-Bladou C, Lepanto L, Lachaine J, Cloutier G, Tang A. Cost-utility analysis of nonalcoholic steatohepatitis screening. Eur Radiol 2015; 25:3282-94. [PMID: 25994191 DOI: 10.1007/s00330-015-3731-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 02/23/2015] [Accepted: 03/20/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in Western countries. No studies have examined the cost-effectiveness of screening its advanced form, nonalcoholic steatohepatitis (NASH). METHODS We performed a cost-utility analysis of annual noninvasive screening strategies using third-party payer perspective in a general population in comparison to screening a high-risk obese or diabetic population. Screening algorithms involved well-studied techniques, including NAFLD fibrosis score, transient elastography (TE), and acoustic radiation force impulse (ARFI) imaging for detecting advanced fibrosis (≥ F3); and plasma cytokeratin (CK)-18 for NASH detection. Liver biopsy and magnetic resonance elastography (MRE) were compared as confirmation methods. Canadian dollar (CAD or C$) costs were adjusted for inflation and discounted at 5%. Incremental cost-effectiveness ratio (ICER) of ≤C$ 50,000 was considered cost-effective. RESULTS Compared with no screening, screening with NAFLD fibrosis score/TE/CK-18 algorithm with MRE as confirmation for advanced fibrosis had an ICER of C$ 26,143 per quality-adjusted life year (QALY) gained. Screening in high-risk obese or diabetic populations was more cost-effective, with an ICER of C$ 9,051 and C$ 7,991 per quality-adjusted life-year (QALY) gained, respectively. Liver biopsy confirmation was not found to be cost-effective. CONCLUSIONS Our model suggests that annual NASH screening in high-risk obese or diabetic populations can be cost-effective. KEY POINTS • This cost-utility analysis suggests that screening for nonalcoholic steatohepatitis may be cost-effective. • In particular, screening of high-risk obese or diabetic populations is more cost-effective. • Magnetic resonance elastography was more cost-effective to confirm disease compared to biopsy. • More studies are needed to determine quality of life in nonalcoholic steatohepatitis. • More management strategies for nonalcoholic steatohepatitis are also needed.
Collapse
Affiliation(s)
- Eric Zhang
- Department of Radiology, Radio-Oncology and Nuclear Medicine, University of Montreal, Saint-Luc Hospital, Montreal, Quebec, Canada
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Claire Wartelle-Bladou
- Department of Gastroenterology and Hepatology, University of Montreal, Saint-Luc Hospital, Montreal, Quebec, Canada
| | - Luigi Lepanto
- Department of Radiology, Radio-Oncology and Nuclear Medicine, University of Montreal, Saint-Luc Hospital, Montreal, Quebec, Canada
- Health Technology Assessment Unit, University of Montreal, Saint-Luc Hospital, Montreal, Quebec, Canada
| | - Jean Lachaine
- Faculty of Pharmacy and Pharmacoeconomics, University of Montreal, Montreal, Quebec, Canada
| | - Guy Cloutier
- Department of Radiology, Radio-Oncology and Nuclear Medicine, University of Montreal, Saint-Luc Hospital, Montreal, Quebec, Canada
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
| | - An Tang
- Department of Radiology, Radio-Oncology and Nuclear Medicine, University of Montreal, Saint-Luc Hospital, Montreal, Quebec, Canada.
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada.
| |
Collapse
|
26
|
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.
Collapse
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.
| |
Collapse
|
27
|
Tome S, Otero E. [Not Available]. Clin Liver Dis (Hoboken) 2015; 5:24-25. [PMID: 31312440 PMCID: PMC6490449 DOI: 10.1002/cld.467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Santiago Tome
- Hepatology Unit. Internal Medicine DepHospital Universitario de SantiagoSantiago de Compostela15706Spain
| | - Esteban Otero
- Hepatology Unit. Internal Medicine DepHospital Universitario de SantiagoSantiago de Compostela15706Spain
| |
Collapse
|
28
|
Tomé S, Otero E. Access to new direct-acting antiviral agents against HCV infection: A view from Spain. Clin Liver Dis (Hoboken) 2015; 5:22-23. [PMID: 31312439 PMCID: PMC6490445 DOI: 10.1002/cld.444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Santiago Tomé
- Hepatology Unit, Internal Medicine DepartmentHospital Universitario de SantiagoSantiago de CompostelaSpain
| | - Esteban Otero
- Hepatology Unit, Internal Medicine DepartmentHospital Universitario de SantiagoSantiago de CompostelaSpain
| |
Collapse
|
29
|
Auxiliary Partial Orthotopic Liver Transplantation as a Treatment for Hemophilia A: A Case Report. Transplant Proc 2015; 47:161-4. [DOI: 10.1016/j.transproceed.2014.08.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 07/11/2014] [Accepted: 08/19/2014] [Indexed: 11/23/2022]
|
30
|
Aberg F, Lempinen M, Hollmén M, Nordin A, Mäkisalo H, Isoniemi H. Neutrophil gelatinase-associated lipocalin associated with irreversibility of pre-liver transplant kidney dysfunction. Clin Transplant 2014; 28:869-76. [PMID: 24930480 DOI: 10.1111/ctr.12394] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2014] [Indexed: 12/30/2022]
Abstract
Kidney outcomes in early post-liver transplantation (LT) are crucial for long-term prognosis, but difficult to predict. Among 203 adult LT patients, we studied the value of plasma neutrophil gelatinase-associated lipocalin (NGAL) measured pre-LT for predicting acute kidney injury (AKI), kidney-replacement therapy within three months, and kidney dysfunction at three months post-LT. Glomerular filtration rate (GFR) was estimated by creatinine-based and cystatin C-based equations. Highest NGAL levels were among patients on pre-LT kidney-replacement therapy, whereas NGAL exceeded 200 μg/L in only three (2%) patients with pre-LT GFR >60 mL/min. Pre-LT NGAL >260 μg/L predicted GFR <60 mL/min at three months post-LT (OR 17.8, 95% CI 2.1-153) independently of 19 other variables reflecting recipient characteristics, liver and kidney function, perioperative hemodynamic stress, and immunosuppression. Of 81 patients with pre-LT GFR <60 mL/min, 48% had GFR <60 mL/min at three months, and an NGAL level >260 μg/L predicted this outcome with 90% specificity and 46% sensitivity. NGAL failed to predict post-LT AKI or need for temporary kidney-replacement therapy. In conclusion, NGAL independently predicted irreversibility of pre-LT kidney dysfunction and could thus help in optimizing patient care and in the decision to perform combined liver-kidney transplantation. Pre-LT NGAL was not useful in patients with preserved pre-LT kidney function or in predicting post-LT AKI.
Collapse
Affiliation(s)
- Fredrik Aberg
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Helsinki, Finland
| | | | | | | | | | | |
Collapse
|
31
|
Abstract
Deceased donor liver transplantation is nowadays a routine procedure for the treatment of terminal liver failure and often represents the only chance of a cure. Under given optimal conditions excellent long-term results can be obtained with 15-year survival rates of well above 60 %.In Germany the outcome after liver transplantation has deteriorated since the introduction of an allocation policy, which is based on the medical urgency. At present 25 % of liver graft recipients die within the first year after transplantation. In contrast 1-year survival in most other countries, e.g. in the USA or the United Kingdom is around 90 % and therefore significantly better. Reasons for the inferior results in Germany are on the one hand an increasing number of critically ill recipients and on the other hand an unfavorable situation for organ donation. In comparison with other countries the organ donation rate is low and moreover the risk profile of these donors is above average. This combination of organ shortage and organ allocation represents a big challenge for the future orientation of liver transplantation and creates the potential for conflict. These cannot be solved on a medical basis but require a social consensus.Because of the present inferior results and because of the high expenses of the present system we suggest a discussion on future allocation policies as well as on future centre structures in Germany. In addition to the medical urgency the maximum benefit should also be considered for organ allocation.
Collapse
Affiliation(s)
- D Seehofer
- Klink für Allgemein-, Viszeral- und Transplantationschirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | | | | |
Collapse
|
32
|
Cucchetti A, Vitale A, Cescon M, Gambato M, Maroni L, Ravaioli M, Ercolani G, Burra P, Cillo U, Pinna AD. Can liver transplantation provide the statistical cure? Liver Transpl 2014; 20:210-7. [PMID: 24166895 DOI: 10.1002/lt.23783] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 10/20/2013] [Indexed: 01/12/2023]
Abstract
Liver transplantation (LT) represents the only chance of long-term survival for patients with end-stage liver disease. When the mortality rate for transplant patients returns to the same level as that for the general population, they can be considered statistically cured. However, cure models in the setting of LT have never been applied. Data from 1371 adult patients undergoing LT for the first time between January 1999 and December 2012 at 2 Italian centers were reviewed in order to establish probabilities of being cured by LT. A parametric Weibull model was applied to compare the mortality rate after LT to the rate expected for the general population (matched by sex and age). The observed 3-, 5-, and 10-year overall survival rates after LT were 77.8%, 73.3%, and 65.6%, respectively, and they did not differ between the 2 centers (P = 0.37). The cure fraction for the entire study population was 63.4% (95% confidence interval = 52.6%-72.0%), and the time to cure was 10 years with a 90% confidence level. The best cure fraction was observed for younger recipients without hepatitis C virus (HCV) who had favorable donor-recipient matches, that is, low Donor Model for End-Stage Liver Disease (D-MELD) scores (90.1%); conversely, the lowest probability was observed for elderly HCV recipients with high D-MELD scores (34.6%). The time to cure was 6.22 years for non-HCV patients and 14.78 years for HCV patients. The median survival time for uncured patients was 2.29 years. Among uncured recipients, the longest survival time was observed for younger patients (7.31 years). In conclusion, we provide here a new clinical measure for LT suggesting that survival after transplantation can approximate that of the general population and provide a statistical cure.
Collapse
Affiliation(s)
- Alessandro Cucchetti
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Vascularized composite allograft transplant survival in miniature swine: is MHC tolerance sufficient for acceptance of epidermis? Transplantation 2014; 96:966-74. [PMID: 24056624 DOI: 10.1097/tp.0b013e3182a579d0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND We have previously reported that Massachusetts General Hospital miniature swine, which had accepted class I-mismatched kidneys long-term after 12 days of high-dose cyclosporine A, uniformly accepted donor-major histocompatibility complex (MHC)-matched kidneys without immunosuppression but rejected donor MHC-matched split-thickness skin grafts by day 25, without changes in renal graft function or antidonor in vitro responses. We have now tested whether this "split tolerance" would also be observed for the primarily vascularized skin of vascularized composite allografts (VCAs). METHODS Group 1 animals (n=3) received donor MHC-matched VCAs less than 70 days after primary kidney transplant (KTx). Group 2 animals (n=3) received a second donor-matched kidney transplant followed by a donor-matched VCA more than 200 days after primary KTx. RESULTS Animals in Group 1 lost the epidermis on days 28, 30, and 40, with all other components of the VCAs remaining viable. Histology showed cellular infiltration localized to dermal-epidermal junction. One of three recipients of VCAs in Group 2, accepted all components of the VCA, including epidermis (>200 days). The other two recipients lost only the epidermis on days 45 and 85, with survival of the remainder of the VCA long-term. CONCLUSIONS All tissues of a VCA are accepted long-term on animals tolerant of class I-mismatched kidneys, with the exception of epidermis, the survival of which is markedly prolonged compared with split-thickness skin grafts but not indefinite. Exposure of tolerant animals to second donor-matched kidneys before VCA increases the longevity of the VCA epidermis, suggesting an increase in the immunomodulatory mechanisms associated with tolerance of the kidney.
Collapse
|
34
|
Cho BH, Stoecker C, Link-Gelles R, Moore MR. Cost-effectiveness of administering 13-valent pneumococcal conjugate vaccine in addition to 23-valent pneumococcal polysaccharide vaccine to adults with immunocompromising conditions. Vaccine 2013; 31:6011-21. [DOI: 10.1016/j.vaccine.2013.10.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 10/03/2013] [Accepted: 10/08/2013] [Indexed: 11/15/2022]
|
35
|
Lai JC, Kahn JG, Tavakol M, Peters MG, Roberts JP. Reducing infection transmission in solid organ transplantation through donor nucleic acid testing: a cost-effectiveness analysis. Am J Transplant 2013; 13:2611-8. [PMID: 24034208 PMCID: PMC4091990 DOI: 10.1111/ajt.12429] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 07/10/2013] [Accepted: 07/11/2013] [Indexed: 01/25/2023]
Abstract
For solid organ transplant (SOT) donors, nucleic acid-amplification testing (NAT) may reduce human immunodeficiency virus (HIV) and hepatitis C virus (HCV) transmission over antibody (Ab) testing given its shorter detection window period. We compared SOT donor NAT + Ab versus Ab alone using decision models to estimate incremental cost-effectiveness ratios (ICERs; cost per quality-adjusted life year [QALY] gained) from the societal perspective across a range of HIV/HCV prevalence values and NAT costs. The cost per QALY gained was calculated for two scenarios: (1) favorable: low cost ($150/donor)/high prevalence (HIV: 1.5%; HCV: 18.2%) and (2) unfavorable: high cost ($500/donor)/low prevalence (HIV: 0.1%; HCV: 1.5%). In the favorable scenario, adding NAT screening cost $161 013 per QALY gained for HIV was less costly) for HCV, and cost $86 653 per QALY gained for HIV/HCV combined. For the unfavorable scenario, the costs were $15 568 484, $221 006 and $10 077 599 per QALY gained, respectively. Universal HCV NAT + Ab for donors appears cost-effective to reduce infection transmission from SOT donors, while HIV NAT + Ab is not, except where HIV NAT is ≤$150/donor and prevalence is ≥1.5%. Our analyses provide important data to facilitate the decision to implement HIV and HCV NAT for deceased SOT donors and shape national policy regarding how to reduce infection transmission in SOT.
Collapse
Affiliation(s)
- J. C. Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA
| | - J. G. Kahn
- Philip R. Lee Institute for Health Policy Studies and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - M. Tavakol
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, San Francisco, CA
| | - M. G. Peters
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA
| | - J. P. Roberts
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, San Francisco, CA
| |
Collapse
|
36
|
The impact of liver transplantation on the phenotype of primary biliary cirrhosis patients in the UK-PBC cohort. J Hepatol 2013; 59:67-73. [PMID: 23466308 PMCID: PMC6976302 DOI: 10.1016/j.jhep.2013.02.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 02/24/2013] [Accepted: 02/25/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND & AIMS Liver transplantation improves survival in end-stage primary biliary cirrhosis (PBC), but the benefit for systemic symptoms including fatigue is less clear. The aim of this study was to utilise the comprehensive UK-PBC Research Cohort, including 380 post-transplant patients and 2300 non-transplanted patients, to answer key questions regarding transplantation for PBC. METHODS Cross-sectional study of post-transplant PBC patients and case-matched non-transplanted patients. Detailed clinical information was collected, together with patient systemic symptom impact data using validated assessment tools. RESULTS Over 25% of patients in the transplant cohort were grafted within 2 years of PBC diagnosis suggesting advanced disease at presentation. Transplanted patients were significantly younger at presentation than non-transplanted (mean 7 years) and >35% of all patients in the UK-PBC cohort who presented under 50 years had already undergone liver transplantation at the study censor point (>50% were treatment failures (post-transplant or unresponsive to UDCA)). Systemic symptom severity (fatigue and cognitive symptoms) was identical in female post-transplant patients and matched non-transplanted controls and unrelated to disease recurrence or immunosuppression type. In males, symptoms were worse in transplanted than in non-transplanted patients. CONCLUSIONS Age at presentation is a major risk factor for progression to transplant (as well as UDCA non-response) in PBC. Although both confirmatory longitudinal studies, and studies utilising objective as well as subjective measures of function, are needed if we are to address the question definitively, we found no evidence of improved systemic symptoms after liver transplantation in PBC and patients should be advised accordingly. Consideration needs to be given to enhancing rehabilitation approaches to improve function and life quality after liver transplant for PBC.
Collapse
|
37
|
Dageforde LA, Feurer ID, Pinson CW, Moore DE. Is liver transplantation using organs donated after cardiac death cost-effective or does it decrease waitlist death by increasing recipient death? HPB (Oxford) 2013; 15:182-9. [PMID: 23374358 PMCID: PMC3572278 DOI: 10.1111/j.1477-2574.2012.00524.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 05/30/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the cost-effectiveness in liver transplantation (LT) of utilizing organs donated after cardiac death (DCD) compared with organs donated after brain death (DBD). METHODS A Markov-based decision analytic model was created to compare two LT waitlist strategies distinguished by organ type: (i) DBD organs only, and (ii) DBD and DCD organs. The model simulated outcomes for patients over 10 years with annual cycles through one of four health states: survival; ischaemic cholangiopathy; retransplantation, and death. Baseline values and ranges were determined from an extensive literature review. Sensitivity analyses tested model strength and parameter variability. RESULTS Overall survival is decreased, and biliary complications and retransplantation are increased in recipients of DCD livers. Recipients of DBD livers gained 5.6 quality-adjusted life years (QALYs) at a cost of US$69 000/QALY, whereas recipients on the DBD + DCD LT waitlist gained 6.0 QALYs at a cost of US$61 000/QALY. The DBD + DCD organ strategy was superior to the DBD organ-only strategy. CONCLUSIONS The extension of life and quality of life provided by DCD LT to patients on the waiting list who might otherwise not receive a liver transplant makes the continued use of DCD livers cost-effective.
Collapse
Affiliation(s)
| | - Irene D. Feurer
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C. Wright Pinson
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Derek E. Moore
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
38
|
Abstract
Model for end-stage liver disease (MELD) score, initially developed to predict survival following transjugular intrahepatic portosystemic shunt was subsequently found to be accurate predictor of mortality amongst patents with end-stage liver disease. Since 2002, MELD score using 3 objective variables (serum bilirubin, serum creatinine, and institutional normalized ratio) has been used worldwide for listing and transplanting patients with end-stage liver disease allowing transplanting sicker patients first irrespective of the wait time on the list. MELD score has also been shown to be accurate predictor of survival amongst patients with alcoholic hepatitis, following variceal hemorrhage, infections in cirrhosis, after surgery in patients with cirrhosis including liver resection, trauma, and hepatorenal syndrome (HRS). Although, MELD score is closest to the ideal score, there are some limitations including its inaccuracy in predicting survival in 15-20% cases. Over the last decade, many efforts have been made to further improve and refine MELD score. Until, a better score is developed, liver allocation would continue based on the currently used MELD score.
Collapse
Key Words
- AH, alcoholic hepatitis
- BAR, balance risk
- CTP, Child–Pugh–Turcotte
- Cirrhosis
- DFI, discriminate function index
- EDC, extended donor criteria
- ESLD, end-stage liver disease
- FHF, fulminant hepatic failure
- GFR, glomerular filtration rate
- HVPG, hepatic venous pressure gradient
- LT, liver transplantation
- Liver transplantation
- MDRD, modification of diet in renal disease
- MELD
- MELD, model for end-stage liver disease
- MLP, multi-layer perceptron
- QALY, quality adjusted life years
- SLK, simultaneous liver kidney transplantation
- SOFA, sequential organ failure assessment
- SOFT, survival outcomes following transplantation
- TIPS, transjugular intrahepatic portosystemic
- UKELD, UK end stage liver disease score
- UNOS, United Network for Organ Sharing
- VH, variceal hemorrhage
- deMELD, drop-out equivalent MELD
Collapse
Affiliation(s)
| | - Patrick S. Kamath
- Address for correspondence: Patrick S. Kamath, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
39
|
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
| |
Collapse
|
40
|
Halldorson JB, Paarsch HJ, Dodge JL, Segre AM, Lai J, Roberts JP. Center competition and outcomes following liver transplantation. Liver Transpl 2013; 19:96-104. [PMID: 23086897 PMCID: PMC4141491 DOI: 10.1002/lt.23561] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 10/12/2012] [Indexed: 12/31/2022]
Abstract
In the United States, livers for transplantation are distributed within donation service areas (DSAs). In DSAs with multiple transplant centers, competition among centers for organs and recipients may affect recipient selection and outcomes in comparison with DSAs with only 1 center. The objective of this study was to determine whether competition within a DSA is associated with posttransplant outcomes and variations in patients wait-listed within the DSA. United Network for Organ Sharing data for 38,385 adult cadaveric liver transplant recipients undergoing transplantation between January 1, 2003 and December 31, 2009 were analyzed to assess differences in liver recipients and donors and in posttransplant survival by competition among centers. The main outcome measures that were studied were patient characteristics, actual and risk-adjusted graft and patient survival rates after transplantation, organ quality as quantified by the donor risk index (DRI), wait-listed patients per million population by DSA, and competition as quantified by the Hirschman-Herfindahl index (HHI). Centers were stratified by HHI levels as no competition or as low, medium (or mid), or high competition. In comparison with DSAs without competition, the low-, mid-, and high-competition DSAs (1) performed transplantation for patients with a higher risk of graft failure [hazard ratio (HR) = 1.24, HR = 1.26, and HR = 1.34 (P < 0.001 for each)] and a higher risk of death [HR = 1.21, HR = 1.23, and HR = 1.34 (P < 0.001 for each)] and for a higher proportion of sicker patients as quantified by the Model for End-Stage Liver Disease (MELD) score [10.0% versus 14.8%, 20.1%, and 28.2% with a match MELD score of 31-40 (P < 0.001 for each comparison)], (2) were more likely to use organs in the highest risk quartile as quantified by the DRI [18.3% versus 27.6%, 20.4%, and 31.7% (P ≤ 0.001 for each)], and (3) listed more patients per million population [18 (median) versus 34 (P = not significant), 37 (P = 0.005), and 45 (P = 0.0075)]. Significant variability in patient selection for transplantation is associated with market variables characterizing competition among centers. These findings suggest both positive and negative effects of competition among health care providers.
Collapse
Affiliation(s)
| | | | - Jennifer L. Dodge
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Alberto M. Segre
- Department of Computer Science, University of Iowa, Iowa City, IA
| | - Jennifer Lai
- Division of Gastroenterology/Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - John Paul Roberts
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| |
Collapse
|
41
|
Fehlings MG, Jha NK, Hewson SM, Massicotte EM, Kopjar B, Kalsi-Ryan S. Is surgery for cervical spondylotic myelopathy cost-effective? A cost-utility analysis based on data from the AOSpine North America prospective CSM study. J Neurosurg Spine 2012; 17:89-93. [DOI: 10.3171/2012.6.aospine111069] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Surgical intervention for appropriately selected patients with cervical spondylotic myelopathy (CSM) has demonstrated favorable outcomes. This study evaluates the cost-effectiveness of this type of surgery in terms of cost per quality-adjusted life year (QALY) gained.
Methods
As part of a larger prospective multicenter study, the direct costs of medical treatment for 70 patients undergoing surgery for CSM at a single institution in Canada were retrospectively obtained from the hospital expenses database and physician reimbursement data. Utilities were estimated on the entire sample of 278 subjects enrolled in the multicenter study using SF-6D–derived utilities from 12- and 24-month SF-36v2 follow-up information. Costs were analyzed from the payer perspective. A 10-year horizon with 3% discounting was applied to health-utilities estimates. Sensitivity analysis was performed by varying utility gain by 20%.
Results
The SF-6D utility gain was 0.0734 (95% CI 0.0557–0.0912, p < 0.01) at 12 months and remained unchanged at 24 months. The 10-year discounted QALY gain was 0.64. Direct costs of medical treatment were estimated at an average of CaD $21,066. The estimated cost-utility ratio was CaD $32,916 per QALY gained. The sensitivity analysis showed a range of CaD $27,326–$40,988 per QALY gained. These estimates are within the limits for medical procedures that have an acceptable cost-utility ratio.
Conclusions
Surgical treatment for CSM is associated with significant improvement in health utilities as measured by the SF-6D. The direct cost of medical treatment per QALY gained places this form of treatment within the category deemed by payers to be cost-effective.
Collapse
Affiliation(s)
- Michael G. Fehlings
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 2Spinal Program,
- 3Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Ontario, Canada; and
| | - Neilank K. Jha
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 3Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Ontario, Canada; and
| | - Stephanie M. Hewson
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 3Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Ontario, Canada; and
| | - Eric M. Massicotte
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 3Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Ontario, Canada; and
| | - Branko Kopjar
- 4Department of Health Services, University of Washington, Seattle, Washington
| | - Sukhvinder Kalsi-Ryan
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 3Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Ontario, Canada; and
| |
Collapse
|
42
|
Karnsakul W, Intihar P, Konewko R, Roy A, Colombani PM, Lau H, Schwarz KB. Living donor liver transplantation in children: a single North American center experience over two decades. Pediatr Transplant 2012; 16:486-95. [PMID: 22672018 DOI: 10.1111/j.1399-3046.2012.01725.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Little data concerning hospital charges and long-term outcomes of LDLT in North American children according to transplant indications have been published. To compare outcomes of patient and graft survival and healthcare charges for LDLT for those with BA vs. other diagnoses (non-BA). A retrospective review of 52 children receiving 53 LDLT (38 BA and 14 non-BA) from 1992 to 2010 at our institution was performed. One-, five-, and 10-yr patient and graft survival data were comparable to national figures reported to UNOS. Average one-yr charges for recipients and donors were $242 849 for BA patients and $183 614 for non-BA (p = 0.074). BA patients were 1.23 ± 1.20 yr of age vs. 4.25 ± 5.02 for non-BA, p = 0.045. Examination of the total population of patients who were alive in 2010 in five chronological groupings showed that the crude five-yr survival rates were 1992-1995: 9/11 (82%); 1995-1997: 6/10 (60%); 1997-1999: 8/10 (80%); 1999-2001: 9/10 (90%); and 2001-2003: 7/7 (100%). Thus, examination of the clinical and financial data together over the entire period of the transplant program suggests that the dramatic improvement in patient survival was accomplished without a dramatic increase in indexed charges. All 53 donors survived, and only 10% had complications requiring hospitalization. LDLT in children results in excellent outcomes for patients and donors. Ways to lower costs and maximize graft outcome should be investigated.
Collapse
Affiliation(s)
- W Karnsakul
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | | | | | | | | | | | | |
Collapse
|