Cost burden of post-transplant lymphoproliferative disease following kidney transplants in Medicare-eligible patients by survival status

AIMS AND OBJECTIVES

Patients diagnosed with post-transplant lymphoproliferative disease (PTLD) experience high mortality within the first 2 years of diagnosis; however, few data exist on the economic burden of PTLD in these patients. We determined the healthcare resource utilization (HRU) and cost burden of post-kidney transplant PTLD and evaluated how these differ by survival status.

MATERIALS AND METHODS

Utilizing data from the United States Renal Data System and the Scientific Registry of Transplant Recipients, we identified 83,818 Medicare-covered kidney transplant recipients between 2007 and 2016, of which 347 had at least one Medicare claim during the first year after diagnosis of PTLD. We tabulated Medicare Part A and Part B and calculated per patient-year (PPY) costs.

RESULTS

Patients diagnosed with PTLD in the first year post-transplant had Part A + B costs of $222,336 PPY, in contrast with $83,546 PPY in all kidney transplants. Post-transplant costs in the first year of PTLD diagnosis were similar regardless of the year of diagnosis. Cost burden for PTLD patients who died within 2 years of diagnosis was >3.3 times higher than PTLD patients still alive after 2 years. Of those who died within 2 years, the majority died within 6 months and costs were highest for these patients, with almost 7 times higher costs than PTLD patients who were still alive after 2 years.

LIMITATIONS

Medicare costs were the only costs examined in this study and may not be representative of other costs incurred, nor be generalizable to other insured populations. Patients were only Medicare eligible for 3 years after transplant unless aged ≥62 years, therefore any costs after this cut-off were not included.

CONCLUSIONS

PTLD represents a considerable HRU and cost burden following kidney transplant, and the burden is most pronounced in patients who die within 6 months.

Posttransplant outcome assessments at listing: Long-term outcomes are more important than short-term outcomes

Posttransplant outcome assessments are publicly reported for patient and regulatory use. However, the currently reported 1-year posttransplant graft survival assessments are commonly criticized for not identifying clinically meaningful differences between programs, and not providing information about longer-term posttransplant outcomes. We investigated the association of different posttransplant outcome assessments available to patients at the time of listing with subsequent posttransplant graft survival. The posttransplant assessments were from period prevalent, rather than incident, cohorts with more timely 1-, 3-, and 5-year follow-up and 6-, 12-, 18-, 24-, and 30-month cohort windows. The association of these assessments at listing with subsequent posttransplant graft survival included candidates listed between July 12, 2011, and December 15, 2015, who subsequently underwent transplant before December 31, 2018. The assessments with 1-year follow-up had uniformly weaker associations than the assessments with 3- and 5-year follow-up. The assessments with 5-year follow-up had the strongest association in kidney and liver transplantation. For kidney, liver, and lung transplantation, assessment windows of at least 18 months typically had the strongest associations with subsequent graft survival. Posttransplant assessments with 5-year follow-up and 18-30-month cohort windows are better than the current posttransplant assessment with 1-year follow-up, particularly at the time of listing.

Effect of Including Important Clinical Variables on Accuracy of the Lung Allocation Score for Cystic Fibrosis and Chronic Obstructive Pulmonary Disease

Rationale: Clinical variables associated with shortened survival in patients with advanced-stage cystic fibrosis (CF) are not included in the lung allocation score (LAS).Objectives: To identify variables associated with wait-list and post-transplant mortality for CF lung transplant candidates using a novel database and to analyze the impact of including new CF-specific variables in the LAS system.Methods: A deterministic matching algorithm identified patients from the Scientific Registry of Transplant Recipients and the Cystic Fibrosis Foundation Patient Registry. LAS wait-list and post-transplant survival models were recalculated using CF-specific variables. This multicenter, retrospective, population-based study of all lung transplant wait-list candidates aged 12 years or older from January 1, 2011, to December 31, 2014, included 9,043 patients on the lung transplant waiting list and 6,110 lung transplant recipients between 2011 and 2014, comprising 1,020 and 677 with CF, respectively.Measurements and Main Results: Measured outcomes were changes in LAS and lung allocation rank. For CF candidates, any Burkholderia sp. (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.2-6.6), 29-42 days hospitalized (HR 2.8; CI 1.3-5.9), massive hemoptysis (HR 2.1; CI 1.1-3.9), and relative drop in FEV₁ ≥30% over 12 months (HR 1.7; CI 1.0-2.8) increased wait-list mortality risk; pulmonary exacerbation time 15-28 days (1.8; 1.1-2.9) increased post-transplant mortality risk. A relative drop in FEV₁ ≥10% in chronic obstructive pulmonary disease (COPD) candidates was associated with increased wait-list mortality risk (HR 2.6; CI 1.2-5.4). Variability in LAS score and rank increased in patients with CF. Priority for transplant increased for COPD candidates. Access did not change for other diagnosis groups.Conclusions: Adding CF-specific variables improved discrimination among wait-listed CF candidates and benefited COPD candidates.

Validating thoracic simulated allocation model predictions for impact of broader geographic sharing of donor lungs on transplant waitlist outcomes

BACKGROUND

The thoracic simulated allocation model (TSAM) is used by the Scientific Registry of Transplant Recipients to predict the relative effect of organ allocation policy changes. A new lung allocation policy changing the first unit of allocation from donation service area to 250 nautical miles took effect on November 24, 2017. We studied TSAM's ability to correctly predict trends caused by changes in allocation policy.

METHODS

We compared the population characteristics from the TSAM cohort, 6,386 lung transplant candidates from 2009 to 2011, with the observed cohort of 7,601 candidates from the year before the policy change on November 24, 2017, and the year after. Simulations were run 10 times. Waitlist mortality and transplant rates were calculated and compared with observed mortality and transplant rates in the years before and after the policy change.

RESULTS

TSAM correctly predicted no change in overall waitlist mortality or transplant rates with the policy change. Observed waitlist mortality values were higher, as were transplant rates, because of increased organ donation and population change. TSAM predicted increased transplant rates for diagnosis group D (idiopathic pulmonary fibrosis), decreased rates for group A (chronic obstructive pulmonary disease), and increased rates for candidates with lung allocation score ≥50, but these changes did not occur in the waitlist and transplant populations after the policy change.

CONCLUSIONS

TSAM correctly predicted the relative trends caused by a change in allocation policy but smaller sub-group predictions were not seen.

Comparing Scientific Registry of Transplant Recipients posttransplant program-specific outcome ratings at listing with subsequent recipient outcomes after transplant

To improve accessibility of program-specific reports to patients, the Scientific Registry of Transplant Recipients released a 5-tier system for categorizing 1-year posttransplant program evaluations. Whether this system predicts subsequent posttransplant outcomes at the time patients are waitlisted has been questioned. We investigated the association of tier at listing and the corresponding continuous score used for tier assignment, which ranges from 0 (poor outcomes) to 1 (good outcomes), with eventual 1-year posttransplant graft survival for candidates listed between July 12, 2011, and June 16, 2014, who underwent transplant before December 31, 2016. One additional tier at listing was associated with better 1-year posttransplant outcomes in liver (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.89-0.97) and lung transplant (HR, 0.90; 95% CI, 0.84-0.97) but not kidney (HR, 0.96; 95% CI, 0.92-1.01) or heart transplant (HR, 1.02; 95% CI, 0.93-1.10). In liver and lung transplant, longer time between listing and transplant was associated with stronger protective effects for high-tier programs. In kidney, liver, and lung transplant, posttransplant evaluations at listing had nonlinear associations with eventual posttransplant outcomes: relatively flat for 5-tier scores <0.5 and decreasing for scores >0.5. After adjustment for measured recipient and donor risk factors, posttransplant evaluations at listing predicted differences in eventual outcomes in liver and lung transplant, providing useful information to patients.

Association of pretransplant and posttransplant program ratings with candidate mortality after listing

The Scientific Registry of Transplant Recipients (SRTR) is responsible for understandable reporting of program metrics, including transplant rate, waitlist mortality, and posttransplant outcomes. SRTR developed five-tier systems for each metric to improve accessibility for the public. We investigated the associations of the five-tier assignments at listing with all-cause candidate mortality after listing, for candidates listed July 12, 2011-June 16, 2014. Transplant rate evaluations with one additional tier were associated with lower mortality after listing in kidney (hazard ratio [HR], _0.93 0.95_0.97 ), liver (HR, _0.87 0.90_0.92 ), and heart (HR, _0.92 0.96_1.00 ) transplantation. For lung transplant patients, mortality after listing was highest at programs with above- and below-average transplant rates and lowest at programs with average transplant rates, suggesting that aggressive acceptance behavior may not always provide a survival benefit. Waitlist mortality evaluations with one additional tier were associated with lower mortality after listing in kidney (HR, _0.94 0.96_0.99 ) transplantation, and posttransplant graft survival evaluations with one additional tier were associated with lower mortality after listing in lung (HR, _0.90 0.94_0.98 ) transplantation. Transplant rate typically had the strongest association with mortality after listing, but the strength of associations differed by organ.

Risk of Second Malignancies in Solid Organ Transplant Recipients Who Develop Keratinocyte Cancers

Solid organ transplant recipients have increased risk for developing keratinocyte cancers, including cutaneous squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), in part as a result of immunosuppressive medications administered to prevent graft rejection. In the general population, keratinocyte cancers are associated with increased risks of subsequent malignancy, however, the risk in organ transplant populations has not been evaluated. We addressed this question by linking the U.S. Scientific Registry of Transplant Recipients, which includes data on keratinocyte cancer occurrence, with 15 state cancer registries. Risk of developing malignancies after keratinocyte cancer was assessed among 118,440 Caucasian solid organ transplant recipients using multivariate Cox regression models. Cutaneous SCC occurrence (n = 6,169) was associated with 1.44-fold increased risk [95% confidence interval (CI), 1.31-1.59] for developing later malignancies. Risks were particularly elevated for non-cutaneous SCC, including those of the oral cavity/pharynx (HR, 5.60; 95% CI, 4.18-7.50) and lung (HR, 1.66; 95% CI, 1.16-2.31). Cutaneous SCC was also associated with increased risk of human papillomavirus-related cancers, including anal cancer (HR, 2.77; 95% CI, 1.29-5.96) and female genital cancers (HR, 3.43; 95% CI, 1.44-8.19). In contrast, BCC (n = 3,669) was not associated with overall risk of later malignancy (HR, 0.98; 95% CI, 0.87-1.12), including any SCC. Our results suggest that transplant recipients with cutaneous SCC, but not BCC, have an increased risk of developing other SCC. These findings somewhat differ from those for the general population and suggest a shared etiology for cutaneous SCC and other SCC in the setting of immunosuppression. Cutaneous SCC occurrence after transplantation could serve as a marker for elevated malignancy risk. Cancer Res; 77(15); 4196-203. ©2017 AACR.

The equitable allocation of deceased donor lungs for transplant in children in the United States

On June 5, 2013, a US Federal Court ordered a temporary restraining order to allow two children within the court's jurisdiction to be registered on the adolescent lung transplant waiting list. On June 10, 2013, the Organ Procurement and Transplantation Network's Executive Committee altered lung allocation policy to offer candidates aged younger than 12 years greater access to adult lungs at the discretion of the national Lung Review Board. The Scientific Registry of Transplant Recipients reviewed trends over time in deceased donor lung transplant waitlist mortality and transplant rates, comparing children and adults. Mortality rates of candidates active on the waiting list have been higher for children aged 0-5 years, but have not differed for children aged 6-11 years compared with adolescents aged 12-17 years or adults aged 18 years or older. Transplant rates among active waitlist candidates have been comparable across all age groups. Thus, there is little evidence that the allocation system led to differences in waitlist mortality or transplant rates for children compared with adults. However, these comparisons are difficult to interpret given that current policies likely led to unaccounted differences in the severity of illness at the time of listing.

Scientific Registry of Transplant Recipients: collecting, analyzing, and reporting data on transplantation in the United States

Founded in 1987, the Scientific Registry of Transplant Recipients (SRTR) operates under a contract from the US government administered by the Health Resources and Services Administration (HRSA). SRTR maintains a database of comprehensive information on all solid organ transplantation in the US. The registry supports the ongoing evaluation of the clinical status of solid organ transplantation, including kidney, heart, liver, lung, intestine, pancreas, and multi-organ transplants. Data in the registry are from multiple sources, but most are collected by the Organ Procurement and Transplantation Network (OPTN) from hospitals, organ procurement organizations, and immunology laboratories. The data include information on current and past organ donors, transplant candidates, transplant recipients, transplant outcomes, and outcomes of living donors. SRTR uses these data to create reports and analyses for HRSA, OPTN committees that make organ allocation policy, and the Centers for Medicare & Medicaid Services to carry out quality assurance surveillance activities; SRTR also creates standard analysis files for scientific investigators. In addition, SRTR and OPTN produce an Annual Data Report and provide information upon request for the general public. Thus, SRTR supports the transplant community with information services and statistical analyses to improve patient access to and outcomes of organ transplant.

Outcomes of renal transplant and waiting list patients with bacterial endocarditis in the United States

BACKGROUND

Bacterial endocarditis is associated with poor long-term survival among dialysis patients. Renal transplant patients and those waiting list for renal transplantation are predisposed to developing bacterial endocarditis; data regarding incidence and outcomes are limited.

METHODS

Patients hospitalised for bacterial endocarditis were identified from patients transplanted or waiting list between 1995 and 2003. Transplant and waiting list cohorts were derived from the United States Renal Data System (USRDS) database. All patients had Medicare as primary payer. Long-term survival was estimated by the Kaplan-Meier method. Cox proportional hazards analysis was used to identify independent predictors of bacterial endocarditis.

RESULTS

During the study period, 282 renal transplant patients and 549 waiting list patients were hospitalised with bacterial endocarditis. Incidence rates of bacterial endocarditis per 1000 patient-years were 5.6 among waiting list patients, 2.6 among deceased-donor transplant recipients and 1.8 among living-donor transplant recipients. In-hospital mortality rates were 16.0% for the renal transplant cohort and 18.6% for the waiting list cohort. Two-year post-endocarditis survival rates were 58% for transplant patients and 41% for waiting list patients. The most powerful predictors of bacterial endocarditis among transplant patients were donor age, patient age, diabetic end-stage renal disease (ESRD) and prior dialysis time longer than 2 years.

CONCLUSIONS

Renal transplant patients hospitalised with bacterial endocarditis sustain high in-hospital and long-term mortality rates. Waiting list patients are at higher risk of developing bacterial endocarditis than renal transplant recipients.

Skin manifestations of inhaled corticosteroids in COPD patients: results from Lung Health Study II

OBJECTIVE

To define the relationship between skin bruising (as well as other cutaneous manifestations) and inhaled corticosteroid (ICS) therapy vs placebo in subjects with COPD who were participating in a clinical trial. To explore the relationship between easy skin bruising and other systemic effects of ICS therapy, including adrenal suppression and loss of bone mineral density (BMD).

DESIGN

Double-blind, randomized, placebo-controlled clinical trial of triamcinolone acetonide (1200 microg daily) vs placebo in participants with mild-to-moderate COPD.

SETTING

Lung Health Study II, a clinical trial to assess the effect of ICS compared to placebo in 1,116 participants in 10 centers over > 3.5 to 4.5 years.

PARTICIPANTS

A total of 1,116 smokers or recent ex-smokers with mild-to-moderate COPD (age range, 40 to 69 years; mean age, 56.3 years; 37.2% female).

MEASUREMENTS AND RESULTS

Every 6 months, a structured questionnaire was administered to elicit reports of any bruising and/or skin rashes, slow healing of cuts or sores, or other skin changes. Compliance with inhaler use was assessed by canister weighing. A significantly higher proportion of ICS than placebo participants who complied with using their inhaler reported easy bruising (11.2% vs 3.5%, respectively) and the slow healing of skin cuts or sores (2.4% vs 0.5%, respectively). Older men in the ICS group with good inhaler compliance appeared to be at the greatest risk of bruising. In those participants undergoing serial measurements of adrenal function and BMD, no association was noted between skin bruising and either the suppression of adrenal function or the loss of BMD as systemic complications of ICS use.

CONCLUSION

These findings indicate that moderate-to-high doses of ICSs result in an increased incidence of easy bruising and impairment in skin healing in middle-aged to elderly persons with COPD. No association was noted between skin bruising and other markers of systemic toxicity from the use of ICSs.

Skin manifestations of inhaled corticosteroids in COPD patients: results from Lung Health Study II

OBJECTIVE

To define the relationship between skin bruising (as well as other cutaneous manifestations) and inhaled corticosteroid (ICS) therapy vs placebo in subjects with COPD who were participating in a clinical trial. To explore the relationship between easy skin bruising and other systemic effects of ICS therapy, including adrenal suppression and loss of bone mineral density (BMD).

DESIGN

Double-blind, randomized, placebo-controlled clinical trial of triamcinolone acetonide (1200 microg daily) vs placebo in participants with mild-to-moderate COPD.

SETTING

Lung Health Study II, a clinical trial to assess the effect of ICS compared to placebo in 1,116 participants in 10 centers over > 3.5 to 4.5 years.

PARTICIPANTS

A total of 1,116 smokers or recent ex-smokers with mild-to-moderate COPD (age range, 40 to 69 years; mean age, 56.3 years; 37.2% female).

MEASUREMENTS AND RESULTS

Every 6 months, a structured questionnaire was administered to elicit reports of any bruising and/or skin rashes, slow healing of cuts or sores, or other skin changes. Compliance with inhaler use was assessed by canister weighing. A significantly higher proportion of ICS than placebo participants who complied with using their inhaler reported easy bruising (11.2% vs 3.5%, respectively) and the slow healing of skin cuts or sores (2.4% vs 0.5%, respectively). Older men in the ICS group with good inhaler compliance appeared to be at the greatest risk of bruising. In those participants undergoing serial measurements of adrenal function and BMD, no association was noted between skin bruising and either the suppression of adrenal function or the loss of BMD as systemic complications of ICS use.

CONCLUSION

These findings indicate that moderate-to-high doses of ICSs result in an increased incidence of easy bruising and impairment in skin healing in middle-aged to elderly persons with COPD. No association was noted between skin bruising and other markers of systemic toxicity from the use of ICSs.

Loss of bone density with inhaled triamcinolone in Lung Health Study II

Inhaled glucocorticosteroids (ICS) are commonly prescribed for chronic obstructive pulmonary disease. No adverse effect on bone mineral density (BMD) has been proven. In a randomized double-blind, placebo-controlled trial at seven centers in North America, we recruited 412 current smokers or recent quitters with mild to moderate chronic obstructive pulmonary disease. They used inhaled triamcinolone acetonide, 600 mcg, or placebo, twice daily. We measured femoral neck and lumbar spine BMD at baseline and after 1 and 3 years, and serum osteocalcin at baseline, 3 months, 1 year, and 3 years. After 3 years, BMD at the femoral neck decreased 1.78% more with ICS than with placebo (p < 0.001). More participants in the ICS group experienced 6% or more loss of femoral neck BMD (p = 0.002). Lumbar spine BMD increased in the placebo group by 0.98% but decreased by 0.35% in the ICS group (a difference of 1.33%, p = 0.007). Changes in osteocalcin did not correlate with changes in BMD. Fractures, lost height, or osteoporosis diagnoses were not increased among ICS users compared with placebo users. In summary, the use of inhaled triamcinolone acetonide was associated with loss of BMD at the femoral neck and lumbar spine after 3 years of treatment.

Effect of inhaled triamcinolone on the decline in pulmonary function in chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) results from a progressive decline in lung function, which is thought to be the consequence of airway inflammation. We hypothesized that antiinflammatory therapy with inhaled corticosteroids would slow this decline.

METHODS

We enrolled 1116 persons with COPD whose forced expiratory volume in one second (FEV1) was 30 to 90 percent of the predicted value in a 10-center, placebo-controlled, randomized trial of inhaled triamcinolone acetonide administered at a dose of 600 microg twice daily. The primary outcome measure was the rate of decline in FEV1 after the administration of a bronchodilator. The secondary outcome measures included respiratory symptoms, use of health care services, and airway reactivity. In a substudy of 412 participants, we measured bone density in the lumbar spine and femur at base line and one and three years after the beginning of treatment.

RESULTS

The mean duration of follow-up was 40 months. The rate of decline in the FEV1 after bronchodilator use was similar in the 559 participants in the triamcinolone group and the 557 participants in the placebo group (44.2+/-2.9 vs. 47.0+/-3.0 ml per year, P= 0.50). Members of the triamcinolone group had fewer respiratory symptoms during the course of the study (21.1 per 100 person-years vs. 28.2 per 100 person-years, P=0.005) and had fewer visits to a physician because of a respiratory illness (1.2 per 100 person-years vs. 2.1 per 100 person-years, P=0.03). Those taking triamcinolone also had lower airway reactivity in response to methacholine challenge at 9 months and 33 months (P=0.02 for both comparisons). After three years, the bone density of the lumbar spine and the femur was significantly lower in the triamcinolone group (P < or = 0.007).

CONCLUSIONS

Inhaled triamcinolone does not slow the rate of decline in lung function in people with COPD, but it improves airway reactivity and respiratory symptoms and decreases the use of health care services for respiratory problems. These benefits should be weighed against the potential long-term adverse effects of triamcinolone on bone mineral density.