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Sabapathy DG, Hosek K, Lam FW, Desai MS, Williams EA, Goss J, Raphael JL, Lopez MA. Identifying drivers of cost in pediatric liver transplantation. Liver Transpl 2024; 30:796-804. [PMID: 38535617 DOI: 10.1097/lvt.0000000000000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/13/2024] [Indexed: 05/09/2024]
Abstract
Understanding the economics of pediatric liver transplantation (LT) is central to high-value care initiatives. We examined cost and resource utilization in pediatric LT nationally to identify drivers of cost and hospital factors associated with greater total cost of care. We reviewed 3295 children (<21 y) receiving an LT from 2010 to 2020 in the Pediatric Health Information System to study cost, both per LT and service line, and associated mortality, complications, and resource utilization. To facilitate comparisons, patients were stratified into high-cost, intermediate-cost, or low-cost tertiles based on LT cost. The median cost per LT was $150,836 [IQR $104,481-$250,129], with marked variance in cost within and between hospital tertiles. High-cost hospitals (HCHs) cared for more patients with the highest severity of illness and mortality risk levels (67% and 29%, respectively), compared to intermediate-cost (60%, 21%; p <0.001) and low-cost (51%, 16%; p <0.001) hospitals. Patients at HCHs experienced a higher prevalence of mechanical ventilation, total parental nutrition use, renal comorbidities, and surgical complications than other tertiles. Clinical (27.5%), laboratory (15.1%), and pharmacy (11.9%) service lines contributed most to the total cost. Renal comorbidities ($69,563) and total parental nutrition use ($33,192) were large, independent contributors to total cost, irrespective of the cost tertile ( p <0.001). There exists a significant variation in pediatric LT cost, with HCHs caring for more patients with higher illness acuity and resource needs. Studies are needed to examine drivers of cost and associated outcomes more granularly, with the goal of defining value and standardizing care. Such efforts may uniquely benefit the sicker patients requiring the strategic resources located within HCHs to achieve the best outcomes.
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Affiliation(s)
- Divya G Sabapathy
- Department of Pediatrics, Baylor College of Medicine, Division of Critical Care Medicine, Houston, Texas, USA
| | - Kathleen Hosek
- Texas Children's Hospital, Department of Quality, Houston, Texas, USA
| | - Fong W Lam
- Department of Pediatrics, Baylor College of Medicine, Division of Critical Care Medicine, Houston, Texas, USA
| | - Moreshwar S Desai
- Department of Pediatrics, Baylor College of Medicine, Division of Critical Care Medicine, Houston, Texas, USA
| | - Eric A Williams
- Department of Pediatrics, Division of Critical Care Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - John Goss
- Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas, USA
| | - Jean L Raphael
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Center for Child Health Policy and Advocacy, Houston, TX, USA
| | - Michelle A Lopez
- Center for Child Health Policy and Advocacy, Houston, TX, USA
- Department of Pediatrics, Baylor College of Medicine, Division of Hospital Medicine, Houston, Texas, USA
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Rea KE, West KB, Dorste A, Christofferson ES, Lefkowitz D, Mudd E, Schneider L, Smith C, Triplett KN, McKenna K. A systematic review of social determinants of health in pediatric organ transplant outcomes. Pediatr Transplant 2023; 27:e14418. [PMID: 36321186 DOI: 10.1111/petr.14418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/27/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Equitable access to pediatric organ transplantation is critical, although risk factors negatively impacting pre- and post-transplant outcomes remain. No synthesis of the literature on SDoH within the pediatric organ transplant population has been conducted; thus, the current systematic review summarizes findings to date assessing SDoH in the evaluation, listing, and post-transplant periods. METHODS Literature searches were conducted in Web of Science, Embase, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases. RESULTS Ninety-three studies were included based on pre-established criteria and were reviewed for main findings and study quality. Findings consistently demonstrated disparities in key transplant outcomes based on racial or ethnic identity, including timing and likelihood of transplant, and rates of rejection, graft failure, and mortality. Although less frequently assessed, variations in outcomes based on geography were also noted, while findings related to insurance or SES were inconsistent. CONCLUSION This review underscores the persistence of SDoH and disparity in equitable transplant outcomes and discusses the importance of individual and systems-level change to reduce such disparities.
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Affiliation(s)
- Kelly E Rea
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Kara B West
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anna Dorste
- Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Debra Lefkowitz
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Mudd
- Cleveland Clinic Children's, Center for Pediatric Behavioral Health, Wilmington, North Carolina, USA
| | - Lauren Schneider
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Courtney Smith
- Norton Children's, University of Louisville, Louisville, Kentucky, USA
| | - Kelli N Triplett
- Children's Health, Children's Medical Center Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Leiskau C, Junge N, Pfister ED, Goldschmidt I, Mutschler F, Laue T, Ohlendorf J, Nasser H, Beneke J, Richter N, Vondran F, Baumann U. Recipient-Specific Risk Factors Impairing Patient and Graft Outcome after Pediatric Liver Transplantation-Analysis of 858 Transplantations in 38 Years. CHILDREN-BASEL 2021; 8:children8080641. [PMID: 34438532 PMCID: PMC8393592 DOI: 10.3390/children8080641] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 12/19/2022]
Abstract
(1) Background and Aim: Despite excellent long-term results in pediatric liver transplantation (pLTx), mortality and graft loss still are to be diminished. We aim to describe time-dependent changes and long-term outcome of a large single-center pLTx cohort and to identify independent recipient-related risk factors impairing patient and graft survival. (2) Methods: This is a retrospective single-center study analyzing all pediatric liver transplants from 1983–2020. Risk factors for mortality and graft loss were identified by univariable and multi-linear regression analysis. (3) Results: We analyzed 858 liver transplantations in 705 pediatric patients. Five-year patient/graft survival increased from 60.9%/48.0% (1983–1992) to 97.5%/86.5% (OR = 12.5; p < 0.0001/OR = 6.5; p < 0.0001) (2014–2020). Indications changed significantly over time, with a higher proportion of patients being transplanted for malignancies and metabolic disease and indications of PFIC and α1AT-deficiency declining. The era of transplantation (log7.378/9.657; p < 0.0001) and indication of acute liver failure (log = 1.944/2.667; HR = 2.015/1.772; p = 0.0114/0.002) impairs patient/graft survival significantly in the multivariate analysis. Furthermore, patient survival is worsened by re-transplantation (log = 1.755; HR = 1.744; p = 0.0176) and prolonged waiting times in high-urgency status (log = 2.588; HR = 1.073; p = 0.0026), whereas the indication of biliary atresia improved outcome (log = 1.502; HR = 0.575; p = 0.0315). Graft survival was additionally impaired by pre-existing portal vein thrombosis (log = 1.482; HR = 2.016; p = 0.0330). (4) Conclusions: Despite more complex indications, patient and graft survival after pLTx continue to improve.. Acute liver failure remains the indication with poorest outcome, and listing for high urgency liver transplantation should be considered carefully and early to keep waiting time on HU list short. Furthermore, pre-transplant portal vein thrombosis should be prevented whenever possible to improve graft survival.
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Affiliation(s)
- Christoph Leiskau
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
- Pediatric Gastroenterology, Department of Pediatrics and Adolescent Medicine, University Medical Centre Göttingen, Georg August University Göttingen, 37073 Göttingen, Germany
- Correspondence: ; Tel.: +49-551-39-67019
| | - Norman Junge
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Eva-Doreen Pfister
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Imeke Goldschmidt
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Frauke Mutschler
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Tobias Laue
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Johanna Ohlendorf
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Hamoud Nasser
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Jan Beneke
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Hannover Medical School, 30625 Hannover, Germany;
| | - Nicolas Richter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, 30625 Hannover, Germany; (N.R.); (F.V.)
| | - Florian Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, 30625 Hannover, Germany; (N.R.); (F.V.)
| | - Ulrich Baumann
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
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Elserafy N, Thompson S, Dalkeith T, Stormon M, Thomas G, Shun A, Sawyer J, Balasubramanian S, Bhattacharya K, Badawi N, Ellaway C. Liver transplantation in children with inborn errors of metabolism: 30 years experience in NSW, Australia. JIMD Rep 2021; 60:88-95. [PMID: 34258144 PMCID: PMC8260479 DOI: 10.1002/jmd2.12219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Inborn errors of metabolism (IEM) are a diverse group of genetic disorders that can result in significant morbidity and sometimes death. Metabolic management can be challenging and burdensome for families. Liver transplantation (LT) is increasingly being considered a treatment option for some IEMs. IEMs are now considered the second most common reason for pediatric LT. AIM To review the data of all children with an IEM who had LT at The Children's Hospital at Westmead (CHW), NSW, Australia between January 1986 and January 2019. METHODS Retrospective data collected from the medical records and genetic files included patient demographics, family history, parental consanguinity, method of diagnosis of IEM, hospital and intensive care unit admissions, age at LT, graft type, clinical outcomes and metabolic management pre and post-LT. RESULTS Twenty-four LT were performed for 21 patients. IEM diagnoses were MSUD (n = 4), UCD (n = 8), OA (n = 6), TYR type I (n = 2) and GSD Ia (n = 1). Three patients had repeat transplants due to complications. Median age at transplant was 6.21 years (MSUD), 0.87 years (UCD), 1.64 years (OA) and 2.2 years (TYR I). Two patients died peri-operatively early in the series, one died 3 months after successful LT due to septicemia. Eighteen LTs have been performed since 2008 in comparison to six LT prior to 2008. Dietary management was liberalized post LT for all patients. CONCLUSIONS Referral for LT for IEMs has increased over the last 33 years, with the most referrals in the last 10 years. Early LT has resulted in improved clinical outcomes and patient survival.
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Affiliation(s)
- Noha Elserafy
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Sue Thompson
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
| | - Troy Dalkeith
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
| | - Michael Stormon
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
- Department of Gastroenterology, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Gordon Thomas
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
- Department of Paediatric Surgery, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Albert Shun
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
- Department of Paediatric Surgery, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Janine Sawyer
- Department of Gastroenterology, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Shanti Balasubramanian
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
| | - Kaustuv Bhattacharya
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
| | - Nadia Badawi
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
- Grace Centre for Newborn Care, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Carolyn Ellaway
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
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Alobaidi R, Anton N, Cave D, Moez EK, Joffe AR. Predicting early outcomes of liver transplantation in young children: The EARLY study. World J Hepatol 2018; 10:62-72. [PMID: 29399279 PMCID: PMC5787685 DOI: 10.4254/wjh.v10.i1.62] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/20/2017] [Accepted: 12/29/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine potentially modifiable predictors of early outcomes after liver transplantation in children of age < 3 years.
METHODS This study was a retrospective chart review including all consecutive children of age less than 3-years-old having had a liver transplant done at the Western Canadian referral center from June 2005 to June 2015. Pre-specified potential predictor variables and primary and secondary outcomes were recorded using standard definitions and a case report form. Associations between potential predictor variables and outcomes were determined using univariate and multiple logistic [odds ratio (OR); 95%CI] or linear (effect size, ES; 95%CI) regressions.
RESULTS There were 65 children, of mean age 11.9 (SD 7.1) mo and weight 8.5 (2.1) kg, with biliary-atresia in 40 (62%), who had a living related donor [LRD; 29 (45%)], split/reduced [21 (32%)] or whole liver graft [15 (23%)]. Outcomes after liver transplant included: ventilator-days of 12.5 (14.1); pediatric intensive care unit mortality of 5 (8%); re-operation in 33 (51%), hepatic artery thrombosis (HAT) in 12 (19%), portal vein thrombosis (PVT) in 11 (17%), and any severe complication (HAT, PVT, bile leak, bowel perforation, intraabdominal infection, retransplant, or death) in 32 (49%) patients. Predictors of the prespecified primary outcomes on multiple regression were: (1) HAT: split/reduced (OR 0.06; 0.01, 0.76; P = 0.030) or LRD (OR 0.16; 0.03, 0.95; P = 0.044) vs whole liver graft; and (2) ventilator-days: surgeon (P < 0.05), lowest antithrombin (AT) postoperative day 2-5 (ES -0.24; -0.47, -0.02; P = 0.034), and split/reduced (ES -12.5; -21.8, -3.2; P = 0.009) vs whole-liver graft. Predictors of the pre-specified secondary outcomes on multiple regression were: (1) any thrombosis: LRD (OR 0.10; 0.01, 0.71; P = 0.021) or split/reduced (OR 0.10; 0.01, 0.85; P = 0.034) vs whole liver graft, and lowest AT postoperative day 2-5 (OR 0.93; 0.87, 0.99; P = 0.038); and (2) any severe complication: surgeon (P < 0.05), lowest AT postoperative day 2-5 (OR 0.92; 0.86-0.98; P = 0.016), and split/reduced (OR 0.06; 0.01, 0.78; P = 0.032) vs whole-liver graft.
CONCLUSION In young children, whole liver graft and surgeon was associated with more complications, and higher AT postoperative day 2-5 was associated with fewer complications early after liver transplantation.
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Affiliation(s)
- Rashid Alobaidi
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta T6G 1C9, Canada
| | - Natalie Anton
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta T6G 1C9, Canada
| | - Dominic Cave
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta T6G 1C9, Canada
| | - Elham Khodayari Moez
- School of Public Health, University of Alberta, Edmonton, Alberta T6G 2B7, Canada
| | - Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta T6G 1C9, Canada
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