Cost-effectiveness of Dual Hypothermic Oxygenated Machine Perfusion Versus Static Cold Storage in DCD Liver Transplantation

Abstract

Background: Ex situ machine perfusion of the donor liver, such as dual hypothermic oxygenated machine perfusion (DHOPE), is increasingly used in liver transplantation. Although DHOPE reduces ischemia/reperfusion-related complications after liver transplantation, data on cost-effectiveness are lacking. Our objective was to evaluate the cost-effectiveness of DHOPE in donation after circulatory death (DCD) liver transplantation.

Methods: We performed an economic evaluation of DHOPE versus static cold storage (SCS) based on a multicenter randomized controlled trial in DCD liver transplantation (DHOPE-DCD trial; ClinicalTrials.gov number, NCT02584283). All patients enrolled in the 3 participating centers in the Netherlands were included. Costs related to the transplant procedure, hospital stay, readmissions, and outpatients treatments up to 1 y posttransplant were calculated. The cost for machine perfusion was calculated using 3 scenarios: (1) costs for machine perfusion, (2) machine perfusion costs plus costs for personnel, and (3) scenario 2 plus depreciation expenses for a dedicated organ perfusion room.

Results: Of 119 patients, 60 received a liver after DHOPE and 59 received a liver after SCS alone. The mean total cost per patient up to 1 y posttransplant was €126 221 for the SCS group and €110 794 for the DHOPE group. The most significant reduction occurred in intensive care costs (28.4%), followed by nonsurgical interventions (24.3%). In cost scenario 1, DHOPE was cost-effective after 1 procedure. In scenarios 2 and 3, cost-effectiveness was achieved after 25 and 30 procedures per year, respectively.

Conclusions: Compared with conventional SCS, machine perfusion using DHOPE is cost-effective in DCD liver transplantation, reducing the total medical costs up to 1 y posttransplant.

FIGURE 1.

Graphic presentation of the mean reduction in costs per patient obtained with DHOPE, compared with the cost for DHOPE in 3 different cost scenarios. Scenario 1 included machine perfusion costs only (perfusion device, disposables, and diagnostics used during machine perfusion). For costs related to the acquisition of a perfusion device, an annual depreciation of 15% was used in accordance with general guidelines for technical equipment. Scenario 2 included machine perfusion costs plus the cost of hiring 2 organ perfusionists. Scenario 3 added the cost for a dedicated OPR unit for organ machine perfusion to the costs calculated for scenario 2, using an annual depreciation of 5%. Cost-effectiveness was most pronounced in scenario 1, but it remained present in scenarios 2 and 3. DHOPE, dual hypothermic oxygenated machine perfusion; OPR unit, organ preservation and resuscitation unit.

FIGURE 2.

Graphic presentation of the minimal number of procedures needed per year for cost-effectiveness in the 3 different scenarios. In scenario 1, reflecting basic machine perfusion costs, DHOPE was cost-effective after 1 procedure per year. For scenario 2 (including personnel costs) and scenario 3 (including costs for personnel and a dedicated OPR unit), the numbers needed for cost-effectiveness were 25 and 30 per year, respectively. The financial breakeven points are indicated by arrows. The color of each arrow indicates the scenario as indicated in the table. DHOPE, dual hypothermic oxygenated machine perfusion; OPR unit, organ preservation and resuscitation unit.

FIGURE 3.

Confidence ellipse of the ICER after bootstrap analysis. The difference in graft survival (DHOPE minus SCS) is presented on the x-axis. The difference in mean costs per graft (DHOPE minus SCS) is depicted in the y-axis. The 95% confidence ellipse is indicated by a dotted line. The ICER is displayed in the middle of the 95% confidence ellipse by a red dot. DHOPE, dual hypothermic oxygenated machine perfusion; ICER, incremental cost-effectiveness ratio; SCS, static cold storage.