Burden of Disease

Economics

The estimated cost of solid organ and haematopoietic stem-cell transplantation (HSCT) procedures in the US for 2014 are shown in the tables below. The total cost was calculated from estimates from 30 days pre-transplantation, procurement, hospital transplantation admission, physicians during transplantation, 180 days post-transplantation admission, and immuno-suppressants for each type of transplantation.

Table 1: Estimated average billed cost of transplantation procedures in the US, pre- and peri-transplant (Milliman, 2014).

Estimated average billed cost of transplantation procedures in the US, pre- and peri-transplant (Milliman, 2014).

 

Table 2: Estimated average billed cost of transplantation procedures in the US, post-transplant (Milliman, 2014).

Estimated average billed cost of transplantation procedures in the US, post-transplant (Milliman, 2014).


In the UK the cost of a kidney transplant was estimated as £17,000 per patient per transplant. The cost includes induction therapy but excludes costs to NHS Blood and Transplant (NHSBT) which may partially explain the wide variation in costs between the USA and countries with a national health system like the UK where total costs are difficult to obtain. The cost of immunosuppression for transplant patients is around £5,000 per patient per year. In comparison, the estimated average cost of dialysis is £30,800 per patient per year.

The cost benefit of kidney transplantation in the second and subsequent years is £25,800 per patient per year. Over 10 years, which is the median survival time of a kidney transplant, the total cost benefit is £241,000 or £24,100 per patient per year. During 2008–09 nearly 2,500 people received a kidney transplant in the UK. Based on this figure, the estimated saving to the NHS from kidney transplantation is £50.3m per year, when compared to the annual costs of dialysis (National Kidney Federation, 2010).

The total Medicare expenditure for solid organ transplant recipients in 2014 was $4.4 billion which was <1% of all Medicare expenditure. Kidney transplantation is recognised as being one of the most cost-effective surgical interventions in medicine, with long-term cost savings. Detailed annual Medicare costs from 2012–2014 for each solid organ transplant are provided in the 2015 OPTN/SRTR Annual Data Report (Schnitzler et al., 2017).

Health-related quality of life (HR-QoL)

Numerous studies have now shown that transplant recipients benefit from an improved quality of life with increased social independence and sense of worth. In addition, many transplant patients resume work which reduces their dependence on state support (NHS England, 2013).

In recent years there has been increased focus on assessment and enhancement of health-related quality of life (HR-QoL) and psychosocial functioning of transplant patients (Fredericks et al., 2014).

HR-QoL in kidney transplantation

Assessment of HR-QoL in kidney transplant recipients (n=205) showed that severity of chronic pain intensity measured by the Visual Analogue Scale (VAS), was lower than haemodialysis patients (n=69), but higher than healthy controls (n=100) (P=0.001) (Nourbala et al., 2007).

Assessment of HR-QoL in long-term (>10 years) kidney transplantation recipients (n=88) using the 36 item Short Form (SF-36) Health Survey showed that HR-QoL scores were significantly lower (P<0.05) than those of the general population for 7 out of the 8 subscales (the exception being bodily pain) (Wei et al., 2013).

HR-QoL in liver transplantation

Fewer studies of QoL have been conducted in patients undergoing liver transplantation, with comparisons of transplant patients being made to the general population. However, the general population may not be the ideal group for these comparisons; with patients with chronic liver disease being a more appropriate comparator.

A review of HR-QoL in adult orthotopic liver transplant recipients concluded that HR-QoL scores were significantly lower than those of healthy patient controls. The physical and mental components of HR-QoL scores improved during the first 6 months post transplantation. However, these increases were not sustained in the long term with emotional and mental HR-QoL scores declining at 1-year post transplantation. From 1 to 5 years post transplantation overall HR-QoL scores declined due to episodes of acute cellular rejection and increasing patient age (>60 years) which was associated with decreased physical function. HR-QoL scores continued to decline after 5 years post transplantation, due to reductions in the physical function and bodily pain domains. This resulted from increasing patient age, osteoporosis, and episodes of chronic rejection (Bownik and Saab, 2009).

In adult transplant recipients (n=104) who survived for more than 15 years after orthotopic liver transplantation, HR-QoL scores were lower in all categories of the 36 item Short Form (SF-36) Health Survey compared to a reference population. With the exception of mental health and bodily pain scores, all categories of the SF-36 (physical functioning, role physical, general health, vitality, social functioning, and role emotional) were significantly less (P<0.001) in transplant recipients than the control group (Kousoulas et al., 2008).

HR-QoL in single-organ transplantation

Comparison of HR-QoL in four single-organ transplant recipients illustrates differences in HR-QoL between the four groups. HR-QoL was compared in single organ transplant patients (n=371) who received either a kidney (n=112), liver (n=100), heart (n=94), or lung (n=65) transplant. Patients were assessed prior to transplantation and followed up for up to four years post transplantation, both using Karnofsky Performance Status (KPS) to objectively assess functional rehabilitation, and subjectively with the SF-36 health survey and the Psychosocial Adjustment to Illness Scale (PAIS) (Pinson et al., 2000).

Pre-transplantation, the mean KPS score for all patients was 54 ± 1, with 22% being assessed as functionally normal (with a score between 80 and 100). Mean KPS scores ranged from 37 ± 1 (severely disabled) for pre-transplant lung patients; to 75 ± 1 (able to self-care but not work) for pre-transplant kidney patients. KAS scores for pre-transplant liver patients were 53 ± 3 (require considerable assistance); and 38 ± 2 (severely disabled) for pre-transplant heart patients. Improvements in KAS scores were found post transplantation for each group (P<0.001 for improvement over time), although there were significant differences between organ time courses (P<0.001 for time by organ) during 2 years of follow-up (Pinson et al., 2000).

The SF-36 physical component scores for all transplants significantly improved after transplantation. Comparisons to pre-transplantation scores showed significant improvements at 12 (P<0.001), 24 (P<0.001), and 36 months (P<0.05). Significant improvement in SF-36 physical component scores following transplantation in heart (P<0.001), lung (P<0.05) and liver (P<0.05) transplant recipients were found, but there was no significant improvement in these scores for kidney transplant patients who had the best health status of the four groups pre-transplantation. For the SF-36 mental health component there were significant improvements following transplantation in heart and lung patients (both P<0.05), with a trend in liver patients (p=0.08) and no significant improvement in kidney transplant patients. The PAIS score improved globally (P<0.01) during the first 36 months post transplantation (Pinson et al., 2000).

Quality of life in adult survivors beyond 10 years in transplant recipients of kidney (n=229), liver (n=126), and heart (n=113) showed that personal function and measures of disease were significantly inferior in each transplant category compared with those of the general population (P<0.0001). In addition, general health perception was significantly lower (P<0.003) in kidney recipients compared to the general population. The index of wellbeing was significantly higher than the general population in liver recipients (P<0.001), of borderline significance in heart recipients (P=0.05) and not significant in kidney recipients (Karam et al., 2003).

HR-QoL, measured using the SF-36 health survey during the first 24 months following kidney (n=165), lung (n=112), liver (n=53) and heart (n=24) transplantation, showed improvement following transplantation but with different trajectories. Liver recipients reported the lowest benefit in HR-QoL for the majority of the physical (P<0.001) and psychosocial (P<0.02) subscales during the 24 months of the survey. In the overall sample, both anxiety (17.4%) and depression (13.8%) were prevalent (Kugler et al., 2013).