The price of “doing the right thing”

There is a fundamental paradox inherent in health care today as the complexity and successes of modern medicine move forward: the most effective care is not always the least expensive. If, from a utilitarian point of view, one measures the effectiveness of liver transplantation (LT) in number of life-years saved, patients with the most severe liver disease at the time of transplantation receive more effective treatment than patients with less severe disease. Moreover, according to the measure of life-years gained, patients with severe disease who are given liver grafts of lower quality receive effective treatment, whereas patients with less severe disease are harmed when they are given higher risk grafts. Several studies using data from the United States or the United Kingdom have amply documented what seems intuitive: LT for sicker patients costs more, even though it may be the more effective treatment, and giving organs at higher risk of failure to high-risk candidates significantly increases costs despite the effectiveness of this practice. These results have now been reconfirmed in a Swiss cohort of patients. In this issue of Liver Transplantation, Dutkowski et al. compare the first 100 LT cases after the introduction of the Model for End-Stage Liver Disease (MELD) score for liver allocation in Switzerland to the 100 LT cases performed immediately before the allocation policy change. Their results were similar to those observed with MELD-based allocation elsewhere: a significant reduction of waiting-list mortality, especially for patients entering the waiting list with higher MELD scores, with no statistically different changes in post-LT patient or graft survival. The combination of waiting-list mortality reduction and maintained post-LT survival resulted in an overall gain in life, especially for recipients with higher MELD scores at transplantation. Notably and in agreement with other studies from the United States, complications (particularly renal failure) and costs were significantly greater for patients undergoing LT with higher MELD scores. There are however, some limitations to this study that readers should consider before they generalize these results. For example, the outcome and cost data are from a single center in Switzerland, and it is not clear whether other Swiss centers have experienced similar results even though all of Switzerland is unified under the same MELD allocation system. The investigators’ center had a high proportion of candidates and recipients with hepatocellular carcinoma and, unlike US centers and some other European centers, evidently used University of California at San Francisco criteria for selection. This could have skewed both outcome and cost results in comparison with other areas in which hepatocellular carcinoma patients are selected by different criteria. In addition, this study used historical controls and as acknowledged by the authors, some of the results were likely more affected by changes in anesthetic, surgical, and organ preservation techniques. More importantly, this group’s use of grafts from donors with more risk factors for graft failure increased from 31% to 48% in the MELD era. This may have had some influence on the rate of complications, including renal failure. Because the evidence suggests that patients prioritized by MELD scores are more likely to have renal impairment at the time of transplantation and renal impairment at transplantation leads to renal complications after LT, it is likely that the change to MELD allocation in Switzerland led to more renal problems