Costs of pediatric liver transplantation among commercially insured and Medicaid-insured patients with cholestasis in the US

Abstract

Children with rare cholestatic liver diseases, such as Alagille syndrome, progressive familial intrahepatic cholestasis, and biliary atresia typically require liver transplantation (LT). The objective of this analysis was to assess the economic burden of LT on these patients. Health care resource utilization and costs associated with pediatric LT were retrospectively assessed using insurance claims data from the US IBM MarketScan Commercial and Medicaid databases collected between October 2015 and December 2019. Inclusion criteria were as follows: ≥1 procedure code for LT, <18 years old at transplant, and ≥6 months of insurance eligibility at baseline. A cholestatic liver disease population who received LT was selected in the absence of specific diagnosis codes by excluding other severe liver conditions (ie, acute liver failure, malignancy) and by excluding severely decompensated individuals requiring ICU admission before LT. Annualized rates were reported. Over a mean study duration of 1.8 years, 53 commercially insured and 100 Medicaid-insured children received LT, with mean (SD) ages at baseline of 6.9 (6.0) and 5.7 (5.4) years, respectively. During this period, commercially insured and Medicaid-insured patients had annualized means of 65.3 and 52.8 medical visits, respectively. Most were outpatient visits, although the burden of inpatient visits was also high, with mean inpatient stays (inclusive of LT stay) of 37.2 and 31.6 days per year, respectively. Commercially insured and Medicaid-insured patients averaged US$512,124 and $211,863 in medical costs and $26,998 and $15,704 in pharmacy costs, respectively. These costs remained substantial throughout the first year after transplant. Overall, pediatric LT resulted in substantial health care resource utilization and cost burden in both commercially- and Medicaid-insured patients. Novel targeted medications that negate the need for pediatric LT could decrease the associated morbidity and costs.

Cost-effectiveness analysis of liver transplantation in biliary atresia according to the severity of end-stage liver disease

“…In post-LT period, the total direct medical cost was peak during the first year after surgery and gradually decreased, similar to previous studies in the US [24] and Canada [25]. Drug cost was the highest among all categories in this study which were mostly contributed by immunosuppressive therapy.…”

“…Currently, the reference price is approximately 470,000-625,000 THB during this period, consisting of 410,000-565,000 THB for the admission during the transplant operation and 60,000 THB for the outpatient care within 3 months after LT. Nevertheless, the cost of LT in this study was lower than the reported cost in North America [24,25].…”

“…The cost of LT is usually peak within 3 months after LT [24], which was defined as the LT-period in this study. From our tornado diagram, the cost of the high PELD score group was the most sensitive parameters affecting the ICER.…”

“…Drug cost was the highest among all categories in this study which were mostly contributed by immunosuppressive therapy. According to the study from the US [24], the cost of drugs is the second highest in the OPD visits, followed the cost of laboratory and radiologic investigations. However, the combination of cost in the investigations was less than the cost of drugs in this study.…”

Identifying drivers of cost in pediatric liver transplantation

“…Our study is thus foundational in the realm of cost analyses in pediatric LT, and emphasizes the pertinence of valuebased health care to this population. [27,28] In addition to total cost, an understanding of cost distribution is central to resource stewardship and high-value care efforts. Our study demonstrated that LT was dominated by "other" costs-a composite of room cost, operating room time, and various fees not related to ancillary patient care services.…”