Competition in liver transplantation: helpful or harmful?

EVALUATION AND SELECTION OF CANDIDATES FOR LIVER TRANSPLANTATION: AN ECONOMIC PERSPECTIVE

BACKGROUND

Over the next 20 years, the number of patients on the waiting list for liver transplantation (LTx) is expected to increase by 23%, while pre-LTx costs should raise by 83%.

OBJECTIVE

To evaluate direct medical costs of the pre-LTx period from the perspective of a tertiary care center.

METHODS

The study included 104 adult patients wait-listed for deceased donor LTx between October 2012 and May 2016 whose treatment was fully provided at the study transplant center. Clinical and economic data were obtained from electronic medical records and from a hospital management software. Outcomes of interest and costs of patients on the waiting list were compared through the Kruskal-Wallis test. A generalized linear model with logit link function was used for multivariate analysis. P-values <0.05 were considered statistically significant.

RESULTS

The costs of patients who underwent LTx ($8,879.83; 95% CI 6,735.24-11,707.27; P<0.001) or who died while waiting ($6,464.73; 95% CI 3,845.75-10,867.28; P=0.04) were higher than those of patients who were excluded from the list for any reason except death ($4,647.78; 95% CI 2,469.35-8,748.04; P=0.254) or those who remained on the waiting list at the end of follow-up.

CONCLUSION

Although protocols of inclusion on the waiting list vary among transplant centers, similar approaches exist and common problems should be addressed. The results of this study may help centers with similar socioeconomic realities adjust their transplant policies.

Organisational structure of liver transplantation in the UK

AIM

This review aims to outline the delivery of liver transplant services in the UK.

BACKGROUND

Liver transplantation in the UK is based on seven designated transplant units serving a population of just over 60 million people. Nearly 900 liver transplants were done in 2013/2014.

PROCESS

Potential deceased donors are identified and referred to centrally employed specialist nurses for obtaining family consent and for donor characterisation. Organs are retrieved by a National Organ Retrieval Service, based on seven abdominal and six cardiothoracic retrieval teams providing a 24/7 service which has shown to be capable of retrieving organs from up to ten donors a day. Donated organs are allocated first nationally to those who qualify for super-urgent listing. The next priority is for splitting livers, and if there is no suitable recipient or the liver is not suitable for splitting, then livers are offered first to the local centre; each centre has a designated donor zone, adjusted annually to ensure equity between the number of patients listed and the number of donors. The allocation scheme is being reviewed, and national schemes based on need, utility and benefit are being assessed.

GOVERNANCE

Outcomes are monitored by National Health Service Blood and Transplant (NHSBT), and if there is a possibility of adverse deviation, then further inquiries are made. Outcomes, both from listing and from transplantation, are published by the centre on the NHSBT website ( www.odt.nhs.uk ). NHSBT works closely with stakeholders primarily through the advisory groups with clinicians, patients, lay members and professional societies and aims to provide openness and transparency.

CONCLUSIONS

The system for organ donation and delivery of liver transplant in the UK has developed and is now providing an effective and efficient service, but there remains room for improvement.