The “opportunity costs” of kidney transplantation (2018)

Financial disincentives faced by transplant centers to the broader utilization of higher-risk deceased and living donor kidney transplants may limit many patients’ access to transplant, despite survival advantages and cost-effectiveness associated with these strategies, according to the analysis provided by Axelrod et al on page 1168. Financial disincentives faced by transplant centers to the broader utilization of higher-risk deceased and living donor kidney transplants may limit many patients’ access to transplant, despite survival advantages and cost-effectiveness associated with these strategies, according to the analysis provided by Axelrod et al on page 1168. For decades, evidence has been available demonstrating the superiority of kidney transplantation for patients with end-stage renal disease (ESRD) compared with dialysis in terms of improved survival, better quality of life, and long-term cost-effectiveness.1Wolfe RA Ashby VB Milford EL et al.Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.N Engl J Med. 1999; 341: 1725-1730Crossref PubMed Scopus (3982) Google Scholar,2Whiting JF Woodward RS Zavala EY et al.Economic cost of expanded criteria donors in cadaveric renal transplantation: analysis of Medicare payments.Transplantation. 2000; 70: 755-760Crossref PubMed Scopus (67) Google Scholar Yet, many barriers continue to exist to increasing patient access to kidney transplant through the use of higher-risk deceased donor kidney transplants (DDKTs) or blood type (ABO) or immunologically (HLA) incompatible living donor kidney transplants (LDKTs). Regulatory issues related to graft and patient outcomes have been raised as a possible impediment to a broader application of these higher-risk strategies. In contrast, the potential imbalance between existing reimbursement schedules and the incremental additional costs of providing these services has not been addressed. The potential for financial losses and “negative kidney margins” may limit the ability or willingness of transplants centers to provide transplant options associated with well-proven clinical benefits. In this issue, Axelrod and colleagues address the economic implications associated with the use of kidney transplant strategies with varying levels of risk compared with continuance of maintenance dialysis.3Axelrod DA, Schnitzler MA, Xiao H, et al. An economic assessment of contemporary kidney transplant practice [published online ahead of print February 16, 2018]. Am J Transplant. https://doi.org/10.1111/ajt.14702Google Scholar In this analysis, the mean survival benefit of transplant over dialysis ranged from a lower limit of a 29% increase with high kidney donor profile index (KDPI) DDKT to an upper limit of 57% increased survival with well-matched LDKT. Only low KDPI DDKT and compatible LDKT were associated with cost-savings compared with dialysis, but it remains true that patients who survive longer will frequently incur higher overall costs over a long-term time horizon. Given this, all but HLA-incompatible LDKT had a lower cost per quality-adjusted life year (QALY) than dialysis. Using metrics more resilient to outliers, such as median differences, the authors demonstrated an even more favorable view of transplant with a survival benefit ranging from 38% to 59% and cost-savings over a 10-year horizon for all transplant strategies other than ABO- or HLA-incompatible LDKT. While the authors’ conclusions regarding the long-term cost and survival benefits of transplant versus dialysis seem obvious and compelling from the societal economic perspective, this analysis has not directly addressed the important issue of financial implications on transplant centers that undertake these riskier and more costly transplant strategies. Medicare diagnosis-related group (DRG) payments and private insurance networks’ global contracts represent a one-size-fits-all approach that leaves transplant centers to shoulder the financial burden of increased costs associated with delayed graft function, desensitization, increased monitoring, and other clinically necessary cost-drivers. Federal directives to the transplant community to increase the number of organs from deceased donors potentially has led to current higher discard rates resulting in increased organ acquisition costs, a significant component of the institutional financial burden. Additionally, many living donors face out-of-pocket costs related to their decision to donate in terms of travel-related costs and lost wages, with more than half of donors experiencing a net financial loss of $1000 and 20% experiencing a loss of more than $5000.4Rodrigue JR Schold JD Morrissey P et al.Direct and indirect costs following living kidney donation: findings from the KDOC study.Am J Transplant. 2016; 16: 869-876Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Addressing the financial disincentives related to the different clinical scenarios discussed in this study for both deceased and living donors should be factored into discussions regarding pursuing these strategies. A number of other relevant and important considerations should also be included in any economic dialogue about transplant strategies raised in this study. High KDPI kidneys have established survival benefits for patients older than 60 years with 36% to 50% reduced mortality hazard.5Jay CL Washburn K Dean PG Helmick RA Pugh JA Stegall MD Survival benefit in older patients associated with earlier transplant with high KDPI kidneys.Transplantation. 2017; 101: 867-872Crossref PubMed Scopus (65) Google Scholar This same patient population has a 50% mortality risk on the kidney waitlist. Accordingly, recent allocation policies designed to direct high KDPI kidneys to these patients was intended in part to decrease organ discard rates. Instead, discard rates for KDPI > 85% kidneys remain close to 60%, raising questions about the economic impact of these policies. Also, given the current US opioid epidemic, the proportion of Public Health Service increased-risk donors has increased dramatically, changing the dynamic of the deceased donor pool with potential improvements in graft quality. Perceived financial disincentives related to monitoring and possible disease transmission may hinder the use of these grafts, which are often from younger, healthier donors. Finally, the role of preemptive transplantation, which has proved benefits in terms of both survival and costs savings,5Jay CL Washburn K Dean PG Helmick RA Pugh JA Stegall MD Survival benefit in older patients associated with earlier transplant with high KDPI kidneys.Transplantation. 2017; 101: 867-872Crossref PubMed Scopus (65) Google Scholar,6Abecassis M Bartlett ST Collins AJ et al.Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQI™) conference.Clin J Am Soc Nephrol. 2008; 3: 471-480Crossref PubMed Scopus (339) Google Scholar also needs to be factored into both economic and financial discussions, especially as related to those raised by the authors. Only through encouraging consideration of all available transplant modalities can optimization of preemptive transplant rates hope to occur. Annual total Medicare spending is $34 billion for patients with ESRD and more than $98 billion for patients with chronic kidney disease and ESRD combined.7United States Renal Data System2017 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2017Google Scholar Therefore, the health economic analyses of the DDKT and LDKT strategies discussed in the report by Axelrod and colleagues are of great import, and the authors should be congratulated for such an in-depth evaluation of these strategies. Addressing how changes in allocation policy and social trends may affect the results of study analyses, and conclusions drawn from these, may help better inform directions needed to improve the cost-utility of various high-risk kidney transplant strategies. More to the point, addressing potential financial barriers to a broader use of various kidney transplant strategies may create real improvements in access to kidney transplant and patient outcomes through reducing time on dialysis and the waitlist. Current reimbursement practices for kidney transplants do not include risk-adjustment according to major comorbidities or complications through the use of a separate DRG code, as used in many inpatient Medicare prospective payment systems, including liver transplants. Consideration of a similar methodology for high KDPI, EPTS, or CPRA scores could help address current financial disincentives posed by their use. According to the Bhimrao Ramji Ambedkar, famed Indian jurist and economist, “History shows that where ethics and economics come in conflict, victory is always with economics.” The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.