Addition of adult-to-adult living donation to liver transplant programs improves survival but at an increased cost

Abstract

Using outcomes data from the Adult-to-Adult Living Donor Liver Transplantation Cohort Study, we performed a cost-effectiveness analysis exploring the costs and benefits of living donor liver transplantation (LDLT). A multistage Markov decision analysis model was developed with treatment, including medical management only (strategy 1), waiting list with possible deceased donor liver transplantation (DDLT; strategy 2), and waiting list with possible LDLT or DDLT (strategy 3) over 10 years. Decompensated cirrhosis with medical management offered survival of 2.0 quality-adjusted life years (QALYs) while costing an average of $65,068, waiting list with possible DDLT offered 4.4-QALY survival and a mean cost of $151,613, and waiting list with possible DDLT or LDLT offered 4.9-QALY survival and a mean cost of $208,149. Strategy 2 had an incremental cost-effectiveness ratio (ICER) of $35,976 over strategy 1, whereas strategy 3 produced an ICER of $106,788 over strategy 2. On average, strategy 3 cost $47,693 more per QALY than strategy 1. Both DDLT and LDLT were cost-effective compared to medical management of cirrhosis over our 10-year study period. The addition of LDLT to a standard waiting list DDLT program is effective at improving recipient survival and preventing waiting list deaths but at a greater cost.

Figure 1

The basic health states of the Markov model.

Figure 2. Mean costs per patient for each treatment strategy by phase of simulation

Costs are reported in 2002 USD with standard deviation. The addition of LDLT to a transplant program significantly decreases pretransplant costs but increases post-transplant and peritransplant costs.

Figure 3. Sensitivity of the model to cost variables

Number shown is percent of cost-dependent model variability attributable to the listed cost as determined by a tornado diagram sensitivity analysis. Note that within the ranges of the sensitivity analysis, none of the cost variability was able to change the fundamental cost-effectiveness of the treatment strategies. See text for details. All values listed as 0.0 were not statistically significant contributors to overall model variability.

Figure 4. Two-way sensitivity analysis on costs of individual transplant procedures

Only unrealistic differences in the cost of the individual procedures would swing the cost-effectiveness superiority to LDLT. See text for details.