A simple risk-based reimbursement system for kidney transplant.

Transplant centers were challenged by the Executive Order on Advancing Kidney health to increase access to kidney transplant (KTx) by accepting higher risk patients and organs. However, Medicare reimbursement for KTx does not include adjustment for major complicating comorbidities (MCCs) like other transplants. The prevalence of MCCs was assessed for KTx performed from 10/15 to 10/19 at a single academic center, using Medicare ICD10 MCC criteria exclusive of end-stage kidney disease. KTx hospital resource utilization and estimated margin, assuming Medicare reimbursement, were determined for cases with and without MCC. Among 260 KTx recipients, 49 (19%) had an MCC. Patients with MCCs had longer wait times (1121 days vs 703 days, P < .001); however, there were no differences in age, gender, race, or diagnosis. Donor characteristics associated with an MCC included greater cold ischemic time (1042 vs 670 minutes, P < .001) and fewer living donor KTx (9% vs 32%, P < .001). KTx cost, exclusive of organ acquisition, was 31% higher (MCC: $38 293 vs No MCC: $29 132) and estimated margin was markedly lower (-$7750 vs -$1001, P = .001). In conclusion, KTx with qualifying MCCs resulted in significant financial losses and modification of KTx payment methodology to align with other organ transplants is needed.

Patient-reported immunosuppression nonadherence 6 to 24 months after liver transplant: association with pretransplant psychosocial factors and perceptions of health status change.

CONTEXT: Knowing the prevalence and risk factors of immunosuppression nonadherence after liver transplant may help guide intervention development. OBJECTIVE: To examine whether sociodemographic and psychosocial variables before liver transplant are predictive of nonadherence after liver transplant. DESIGN: Structured telephone interviews were used to collect self-report immunosuppression adherence and health status information. Medical record reviews were then completed to retrospectively examine the relationship between immunosuppression adherence and pretransplant variables, including sociodemographic and medical characteristics and the presence or absence of 6 hypothesized psychosocial risk factors. SETTING AND PARTICIPANTS: A nonprobability sample of 236 adults 6 to 24 months after liver transplant at 2 centers completed structured telephone interviews. MAIN OUTCOME MEASURE: Immunosuppressant medication nonadherence, categorized as missed-dose and altered-dose "adherent" or "nonadherent" during the past 6 months; immunosuppression medication holidays. RESULTS: Eighty-two patients (35%) were missed-dose nonadherent and 34 patients (14%) were altered-dose nonadherent. Seventy-one patients (30%) reported 1 or more 24-hour immunosuppression holidays in the past 6 months. Missed-dose nonadherence was predicted by male sex (odds ratio, 2.46; P= .01), longer time since liver transplant (odds ratio, 1.08; P= .01), pretransplant mood disorder (odds ratio, 2.52; P=.004), and pretransplant social support instability (odds ratio, 2.25; P=.03). Altered-dose nonadherence was predicted by pretransplant mood disorder (odds ratio, 2.15; P= .04) and pretransplant social support instability (odds ratio, 1.89; P= .03). CONCLUSION: Rates of immunosuppressant nonadherence and drug holidays in the first 2 years after liver transplant are unacceptably high. Pretransplant mood disorder and social support instability increase the risk of nonadherence, and interventions should target these modifiable risk factors.

Effect of prophylaxis on fungal infection and costs for high-risk liver transplant recipients.

We sought to determine whether the prophylactic use of amphotericin B products (conventional amphotericin B and liposomal amphotericin B) reduces the incidence of fungal infections in high-risk liver transplant recipients, and if so, whether this lowers the cost of care. The study sample comprised 232 adult orthotopic liver transplants performed from 1994 to 2005 at a single center for patients classified as being at high risk for fungal infections. High-risk patients who received transplants with a prophylaxis regimen of amphotericin B (n=58 transplants) were compared with high-risk patients who received no prophylaxis (n=174 transplants). Fungal infections occurred in 3 transplants (5.17%) of those who received amphotericin B and 28 transplants (16.09%) in those without prophylaxis (P=0.0432). Regression models were used to analyze fungal infection and costs for the 232 high-risk transplants. Failure to offer prophylaxis conferred a 4-fold greater risk of fungal infection (P=0.046) compared with those who received amphotericin B. A fungal infection in a high-risk recipient increased mean costs by 46.48%. The indirect effect of prophylaxis (operating through infection reduction) is estimated to reduce overall costs in high-risk patients by 8.73%.

The financial burden of transplantation: a single-center survey of liver and kidney transplant recipients.

Little is known about the financial impact of transplantation on patients and families. We interviewed 333 liver transplant (LT) and 318 kidney transplant (KT) recipients who were at least 1 year posttransplant. Patients were asked whether transplantation caused financial problems, whether income had changed since transplantation, what resources they used to pay for transplant-related expenses, and what their out-of-pocket monthly expenses were. Descriptive and comparative statistics, measures of association, and logistic regression analyses were calculated. Many patients reported financial problems secondary to transplantation (40.6%) and less monthly income now than in the year preceding transplantation (46.5%). Average monthly out-of-pocket expense was $476.60. LT recipients had higher out-of-pocket expenses than KT recipients (t=2.46, P=0.015). Patients used personal savings (53.9%) and credit cards (25.0%) to help offset these expenses, among other strategies. For both LT and KT recipients, older age, nonworking status before transplantation, and current nonworking status predicted greater financial impact, whereas younger age and current nonworking status predicted higher monthly out-of-pocket expenses. These findings highlight the potential financial impact of transplantation on patients and families, and they have implications for assisting patients in managing out-of-pocket expenses after transplantation.