Who pays for biliary complications following liver transplant? A business case for quality improvement.

We use biliary complication following liver transplantation to quantify the financial implications of surgical complications and make a case for surgical improvement initiatives as a sound financial investment. We reviewed the medical and financial records of all liver transplant patients at the UMHS between July 1, 2002 and June 30, 2005 (N = 256). The association of donor, transplant, recipient and financial data points was assessed using both univariable (Student's t-test, a chi-square and logistic regression) and multivariable (logistic regression) methods. UMHS made a profit of $6822 +/- 39087 on patients without a biliary complication while taking a loss of $5742 +/- 58242 on patients with a biliary complication (p = 0.04). Reimbursement by the payer was $5562 higher in patients with a biliary complication compared to patients without a biliary complication (p = 0.001). Using multivariable logistic regression analysis, the two independent risk factors for a negative margin included private insurance (compared to public) (OR 1.88, CI 1.10-3.24, p = 0.022) and biliary leak (OR = 2.09, CI 1.06-4.13, p = 0.034). These findings underscore the important impact of surgical complications on transplant finances. Medical centers have a financial interest in transplant surgical quality improvement, but payers have the most to gain with improved surgical outcomes.

Retransplantation for late liver graft failure: predictors of mortality.

As patient survival after orthotopic liver transplantation (OLT) improves, late complications, including late graft failure, more commonly occur and retransplantation (re-OLT) is required more often. Survival after re-OLT is poorer than after primary OLT, and given the organ shortage, it is essential that we optimize our use of scarce donor livers. We sought to identify variables that predict poor outcome after late re-OLT. Among adults who underwent OLT between September 1989 and October 1997, we identified transplant recipients who survived greater than 6 months (n = 964) and analyzed those who required late re-OLT (>/=6 months after primary OLT). We recorded the indication for the initial OLT and interval from OLT to re-OLT. We also analyzed data collected at the time of re-OLT, including age, sex, indications for primary OLT and re-OLT, United Network for Organ Sharing status, preoperative laboratory values (white blood cells, platelets, hemoglobin, albumin, bilirubin, creatinine, and prothrombin time), Child-Pugh-Turcotte score, number of rejection episodes before re-OLT, and interval between OLT and re-OLT. In addition, we analyzed surgical factors (including procedure performed and use of packed red blood cells, fresh frozen plasma, and platelets), postoperative immunosuppression, and donor factors (age, ischemic time). Forty-eight patients (5%) underwent late re-OLT at a median of 557 days (range, 195 to 2,559 days) post-OLT. Survival rates after re-OLT at 90 days, 1 year, and 5 years were 71%, 60%, and 42%, respectively. Patients surviving 90 days or greater after re-OLT had an 85% chance of surviving to 1 year. Sepsis was the leading cause of death (15 of 25 deaths; 60%). Recipient age older than 50 years (P =.04), preoperative creatinine level greater than 2 mg/dL (P =.004), and use of intraoperative blood products (packed red blood cells, P =.001; fresh frozen plasma, P =.002; platelets, P =.004) had significant impacts on survival. Late re-OLT was associated with increased mortality. Careful patient selection, with particular attention to recipient age and renal function, may help improve results and optimize our use of scarce donor livers.