Discount pricing and the "cost" of liver transplantation

Context: Liver transplantation is among the most costly of medical services, yet few studies have addressed the relationship between the resources utilized for this procedure and specific patient characteristics and clinical practices. Objective: To assess the association of pretransplant patient characteristics and clinical practices with hospital resource utilization. Design: Prospective cohort of patients who received liver transplants between January 1991 and July 1994. Setting: University of California, San Francisco; Mayo Clinic, Rochester, Minn; and the University of Nebraska, Omaha. Patients: Seven hundred eleven patients who received single-organ liver transplants, were at least 16 years old, and had nonfulminant liver disease. Main Outcome Measure: Standardized resource utilization derived from a database created by matching all services to a single price list. Results: Higher adjusted resource utilization was associated with donor age of 60 years or older (28% [$53 813] greater mean resource utilization; P =.005), recipient age of 60 years or older (17% [$32 795]; P =.01), alcoholic liver disease (26% [$49 596]; P =.002), Child-Pugh class C (41% time of transplant (42% [$77 833]; P <.001); death in the hospital (35% [$67 076]; P <.001); and having multiple liver transplants during the index hospitalization (154% increase [$474 740 vs $186 726 for 1 transplant]; P <.001). Adjusted length of stay and resource utilization also differed significantly among transplant centers. Conclusions: Clinical, economic and ethical dilemmas in liver transplantation are highlighted by these findings. Recipients who were older, had alcoholic liver disease, or were severely ill were the most expensive to treat; this suggests that organ allocation criteria may affect transplant costs. Clinical practices and resource utilization varied considerably among transplant centers; methods to reduce variation in practice patterns, such as clinical guidelines, might lower costs while maintaining quality of care.