Clinical outcomes and costs associated with in-hospital biliary complications after liver transplantation: a cross-sectional analysis

Abstract

Introduction: In-hospital biliary complications (BCs) after liver transplantation (LT) are reported in up to 20 % of patients and contribute to poor outcomes and increased costs. Existing single-center outcome and cost analyses studies are limited in scope.

Methods: This is a cross-sectional analysis of national data involving 7,967 patients transplanted between 2011 and 2012 with the primary aim of determining the association between BCs and clinical outcomes and costs. Age, race, diagnosis, and severity of illness are associated with the development of BCs.

Results: BCs develop in 14.6 % of LT recipients and have substantial implications for perioperative outcomes, including length of hospital and ICU stay (27.9 vs 19.6 mean days, p < 0.001 and 12.0 vs 8.3 mean days, p < 0.001, respectively), in-hospital morbidity (39 vs 27 %, p < 0.001), 30-day readmissions (14.8 vs 11.2 %, p < 0.001), and in-hospital mortality (5.8 vs 4.0 %, p < 0.001). BCs contributed to a mean increase in in-hospital costs of $36,212 (p < 0.001), due to increases in accommodations ($9,539, p < 0.001), surgical services ($3,988, p < 0.001), and pharmacy services ($8,445, p < 0.001).

Discussion: BCs are a predominant etiology for in-hospital morbidity and mortality, while contributing significantly to the high cost of LT. Efforts should be focused on understanding salient and modifiable risk factors, while developing innovative strategies to reduce BCs.

Figure 1. Differences between the BCs and control cohort in the overall costs, observed direct costs, and expected direct costs

The bar graph to the left represents costs differences, comparing those that developed a biliary complication to those that did not. The higher number represents increased costs that were associated with biliary complications. For example, overall mean cost difference was $225,303 – $189,091. The chart to the right represents the mean direct cost index, calculating using the observed-to-expected cost ratios for those with and without biliary complications. A direct cost index of 1·00 represents an expected direct cost. The direct cost index for patients with biliary complications was 1·13±0·41 vs. 1·02±0·53 for those without such complication (p<0·001).

Figure 2. Mean cost difference between cohorts (those that developed a perioperative biliary complication vs. those that did not)

The mean cost difference is delineated based on categories, with a positive cost representing an increased cost associated with a biliary complication and a negative costs representing a lower cost associated with biliary complications. The error bars represent the 95% confidence interval. Bars crossing the dotted line (0-axis) are statistically insignificant cost differences.