Payment for Living Donor (Vendor) Kidneys: A Cost-Effectiveness Analysis

The supply of kidneys does not meet the demand. As a consequence, the waiting time for a cadaver kidney continues to lengthen, and there is renewed debate about payment for living donors. To facilitate this debate, we studied what amount of payment would be cost-effective for society, i.e. what costs would be saved (if any) by removing a patient from the waiting list using a paid (living unrelated: LURD) donor-vendor. A Markov model was developed to calculate the expected average cost and outcome benefits of increasing the organ supply and reducing waiting times by adding paid LURD organs to the available pool. We found that a LURD transplant saved $94,579 (US dollars, 2002), and 3.5 quality-adjusted life years (QALYs) were gained. Adding the value of QALYs, a LURD transplant saved $269 319, assuming society values additional QALYs from transplantation at the rate paid per QALY while on dialysis. At a minimum, a vendor program would save society >$90,000 per transplant and provides QALYs for the ESRD population. Thus, society could break even while paying $90,000/kidney vendor.     

Cost-Effectiveness of Policies Aimed at Increasing Organ Donation: The Case of Chile

BackgroundIn this article we present an economic evaluation of policies aimed at increasing deceased organ donation in Chile, a developing country that has low donation rates; it had 5.4 donors per million people (pmp) in 2010.MethodsExpert opinions of leading participants in donation and transplantation were analyzed, resulting in a set of local policies aimed at increasing donation rates. Using previous results of reported cost savings of increasing kidney transplantation in Chile, we estimated the net benefits of these policies, as a function of additional donors.ResultsThe main problem of the Chilean system seems to be the low capability to identify potential donors and a deficit in intensive care unit (ICU) beds. Among considered policies central to increase donation are the following: increasing human and capital resources dedicated to identifying potential donors, providing ICU beds from private centers, and developing an online information system that facilitates procurement coordination and the evaluation of performance at each hospital. Our results show that there is a linear relationship between cost savings and incremental donors pmp. For example, if these policies are capable of elevating donation rates in Chile by 6 donors pmp net estimated cost savings are approximately US $1.9 million. Likewise, considering the effect on patients' quality of life, savings would amount to around $15.0 million dollars per year.ConclusionsOur estimates suggest that these policies have a large cost-saving potential. In fact, considering implementation costs, cost reduction is positive after 4 additional donors pmp, and increasing afterward.     

Cost-benefit approach in evaluating investment into donor action: the German case

Donor Action (DA) is an international initiative to help critical care units (CCUs) increase their own donation rates through improved-quality donation practices. Following a validated diagnostic review (DR), areas of weakness can be identified, and the appropriate changes introduced. Data gathered from a number of centers in nine European countries (including Germany) 1 year after the introduction of targeted improvement measures demonstrated a 59.2% (P=0.0015) increase in donation rates. This analysis computes the cost-benefit thresholds of implementing the DA methodology from a German health-economic point of view, taking into account the treatment alternatives for end-stage renal disease (dialysis and transplantation) and comparing the DA program with current organ-donation practice. Lifetime direct medical costs and quality-adjusted life years (QALYs) were calculated for both arms, considering only changes in cadaveric renal transplantation rates. If DA leads to a 59% overall increase in organ donation in Germany, the program will result in 33 QALYs and 1.8-million euro cost savings per million population (PMP). Therefore, DA would be cost-effective below 2.66-million euro implementation cost PMP (or 218-million euro for the whole country). As the partial implementation cost of the program was far below the threshold, DA is more cost-effective than other publicly reimbursed medical intervention.     

An economic assessment of contemporary kidney transplant practice

Kidney transplantation is the optimal therapy for end‐stage renal disease, prolonging survival and reducing spending. Prior economic analyses of kidney transplantation, using Markov models, have generally assumed compatible, low‐risk donors. The economic implications of transplantation with high Kidney Donor Profile Index (KDPI) deceased donors, ABO incompatible living donors, and HLA incompatible living donors have not been assessed. The costs of transplantation and dialysis were compared with the use of discrete event simulation over a 10‐year period, with data from the United States Renal Data System, University HealthSystem Consortium, and literature review. Graft failure rates and expenditures were adjusted for donor characteristics. All transplantation options were associated with improved survival compared with dialysis (transplantation: 5.20‐6.34 quality‐adjusted life‐years [QALYs] vs dialysis: 4.03 QALYs). Living donor and low‐KDPI deceased donor transplantations were cost‐saving compared with dialysis, while transplantations using high‐KDPI deceased donor, ABO‐incompatible or HLA‐incompatible living donors were cost‐effective (<$100 000 per QALY). Predicted costs per QALY range from $39 939 for HLA‐compatible living donor transplantation to $80 486 for HLA‐incompatible donors compared with $72 476 for dialysis. In conclusion, kidney transplantation is cost‐effective across all donor types despite higher costs for marginal organs and innovative living donor practices.     

Cost-Effectiveness of Organ Donation: Evaluating Investment into Donor Action and Other Donor Initiatives

Initiatives aimed at increasing organ donation can be considered health care interventions, and will compete with other health care interventions for limited resources. We have developed a model capable of calculating the cost-utility of organ donor initiatives and applied it to Donor Action, a successful international program designed to optimize donor practices. The perspective of the payer in the Canadian health care system was chosen. A Markov model was developed to estimate the net present value incremental lifetime direct medical costs and quality adjusted life years (QALYs) as a consequence of increased kidney transplantation rates. Cost-saving and cost-effectiveness thresholds were calculated. The effects of changing the success rate and time frame of the intervention was examined as a sensitivity analysis. Transplantation results in a gain of 1.99 QALYs and a cost savings of Can$104,000 over the 20-year time frame compared with waiting on dialysis. Implementation of an intervention such as Donor Action, which produced as few as three extra donors per million population, would be cost-effective at a cost of Can$1.0 million per million population. The cost-effectiveness of Donor Action and other organ donor initiatives compare favorably to other health care interventions. Organ donation may be underfunded in North America.     

Comparative effectiveness of donation after cardiac death versus donation after brain death liver transplantation: Recognizing who can benefit

Due to organ scarcity and wait-list mortality, transplantation of donation after cardiac death (DCD) livers has increased. However, the group of patients benefiting from DCD liver transplantation is unknown. We studied the comparative effectiveness of DCD versus donation after brain death (DBD) liver transplantation. A Markov model was constructed to compare undergoing DCD transplantation with remaining on the wait-list until death or DBD liver transplantation. Differences in life years, quality-adjusted life years (QALYs), and costs according to candidate Model for End-Stage Liver Disease (MELD) score were considered. A separate model for hepatocellular carcinoma (HCC) patients with and without MELD exception points was constructed. For patients with a MELD score <15, DCD transplantation resulted in greater costs and reduced effectiveness. Patients with a MELD score of 15 to 20 experienced an improvement in effectiveness (0.07 QALYs) with DCD liver transplantation, but the incremental cost-effectiveness ratio (ICER) was >$2,000,000/QALY. Patients with MELD scores of 21 to 30 (0.25 QALYs) and >30 (0.83 QALYs) also benefited from DCD transplantation with ICERs of $478,222/QALY and $120,144/QALY, respectively. Sensitivity analyses demonstrated stable results for MELD scores <15 and >20, but the preferred strategy for the MELD 15 to 20 category was uncertain. DCD transplantation was associated with increased costs and reduced survival for HCC patients with exception points but led to improved survival (0.26 QALYs) at a cost of $392,067/QALY for patients without exception points. In conclusion, DCD liver transplantation results in inferior survival for patients with a MELD score <15 and HCC patients receiving MELD exception points, but provides a survival benefit to patients with a MELD score >20 and to HCC patients without MELD exception points.     

Cadaveric versus living donor kidney transplantation: a Medicare payment analysis

BACKGROUND: We found previously that the clinical advantages of living donor (LD) renal transplantation lead to financial cost savings compared to either cadaveric donation (CAD) or dialysis. Here, we analyze the sources of the cost savings of LD versus CAD kidney transplantation. METHODS: We used United States Renal Data System data to merge United Network for Organ Sharing registry information with Medicare claims data for 1991-1996. Information was available for 42,868 CAD and 13,754 LD transplants. More than 5 million Medicare payment records were analyzed. We calculated the difference in average payments made by Medicare for CAD and LD for services provided during the first posttransplant year. RESULTS: Average total payments were $39,534 and $24,652 for CAD and LD, respectively (P<0.0001) during the first posttransplant year. The largest source of the difference in payments was in inpatient hospitals, representing $10,653.67 (P<0.0001). For patients who had Medicare as the primary payer, average transplant charges were significantly higher for CAD donation ($79,730 vs. $69,547, P<0.0001); average transplant payments demonstrated no statistical differences ($28,483 vs. $28,447, P = 0.858). Therefore, inferred profitability was significantly higher for LD. CONCLUSIONS: Medicare payments are remarkably lower for LD compared to CAD in every category. The single largest cost saving comes from inpatient hospital services. A portion of the savings from LD could be invested in programs to expand living kidney donation.     

Donor-recipient relationships in African American vs. Caucasian live kidney donors

Reeves‐Daniel A, Bailey A, Assimos D, Westcott C, Adams PL, Hartmann EL, Rogers J, Farney AC, Stratta RJ, Daniel K, Freedman BI. Donor–recipient relationships in African American vs. Caucasian live kidney donors.
Clin Transplant 2011: 25: E487–E490. © 2011 John Wiley & Sons A/S. Abstract: Purpose: The purpose of the study was to characterize differences in donor and recipient relationships between African American (AA) and Caucasian living kidney donors. Methods: Data from all successful living kidney donors at a single institution between 1991 and 2009 were reviewed. Relationships between donor and recipient were categorized and between‐group comparisons performed. Results: The study sample consisted of 73 (18%) AA and 324 Caucasian living kidney donors. The distribution of donor–recipient relationships differed significantly between AA and Caucasians. AA donors were more likely to be related to the recipient (88% vs. 74%, p = 0.007) than Caucasians. AA donors were more likely to participate in child to parent donation and were less likely to participate in parent to child donation or to donate to unrelated individuals. Sibling and spousal donations were similar in both groups. Caucasian donors were more likely to be unrelated to the recipient than AA donors. Conclusions: Differences exist in donor–recipient relationships between AA and Caucasian living kidney donors. Future studies exploring cultural differences and family dynamics may provide targeted recruitment strategies for AA and Caucasian living kidney donors. Living unrelated kidney transplantation appears to be a potential growth area for living kidney donation in AA.     

Procuring organ donors as a health investment: how much should we be willing to spend?

BACKGROUND: This paper examines the benefits and costs that accrue when a cadaveric organ donor is procured. We estimate the cost per quality-adjusted life year (QALY) for donor procurement. Our objective was not only to see whether organ procurement is a "good" health investment, but also to clarify how much it is worth spending to obtain additional donors. METHODS: We calculated the average number of kidney, heart, and liver transplants that a typical cadaveric donor generates. Relying primarily on reviewing the published literature, we estimated for each organ type the average number of QALYs that transplants add and the average medical costs they generate. We multiplied per organ benefits and costs by the number of organs from the typical donor, and summed the results to calculate the cost per QALY from procuring an additional donor. We conducted extensive sensitivity analyses of the assumptions. RESULTS: Our central estimate indicates that the typical donor generates about 13 QALYs at an added medical cost of about $214,000, a cost of approximately $16,000 per QALY. Our high estimate is approximately $57,000. CONCLUSIONS: The implications of these findings depend upon how we choose to value QALYs. Most analysts agree that a figure of $100,000 is reasonable. At this value, the benefit obtained from one added donor would be $1.3 million (13 x $100,000) while the medical costs would be $214,000. The implication is that we should be willing to spend up to $1,086,000 ($1.3 million - $214,000) to obtain one more donor.     

How deceased donor transplantation is impacting a decline in commercial transplantation-the Tamil Nadu experience

India with a population of 1.2 billion has a renal transplantation rate of 3.25 per million population. The major cause of chronic kidney disease is hypertension and diabetes. The crude and age-adjusted incidence rates of end-stage renal disease are estimated to be 151 and 232 per million population, respectively, in India. There was a remarkable lack of knowledge in the public about deceased organ donation until a decade ago. However, the role played by the media and nongovernmental organizations in partnership with the government has emphasized and implemented deceased donor transplantation in certain states in India-to mention particularly, the Tamil Nadu model. In the last 2 years, deceased organ donation has reached 1.3 per million population in Tamil Nadu, thereby effectively eliminating commercial transplantation. There is no religious bar for organ donation. A central transplant coordinator appointed by the government oversees legitimate and transparent allocation of deceased organs both in the public and private facilities as per the transplant waiting list. This model also takes care of the poor sections of society by conducting donation and transplantation through government-run public facilities free of cost. In the last 2 years, deceased donor transplantation has been performed through this network procuring organs such as the heart, heart valves, lung, liver, kidneys, cornea, and skin. The infrastructural lack of immunological surveillance-including donor-specific antibody monitoring, human leukocyte antigen typing, and panel reactive antibody except in a few tertiary care centers-prevents allocation according to the immunological status of the recipient. This private-public partnership promoting deceased donor transplantation has effectively eliminated commercialization in transplantation in the state of Tamil Nadu with a population of 72 million which is a model for other regions of South Asia and developing countries.     

Cost-benefit estimation of cadaveric kidney transplantation: the case of a developing country

Background

In this paper we have estimated the cost savings for the health care system and quality-of-life improvement for patients from an increased number of kidney transplants in Chile. We compared the present value of dialysis and transplantation costs and quality of life over a 20-year horizon.

Methods

We used Markov models and introduced some degree of uncertainty in the value of some of the parameters that built the model. Using Monte Carlo simulations, we estimated the confidence intervals for our results.

Results

Our estimates suggested that a kidney transplant showed an expected savings value of US$28,000 for the health care system. If the quality-of-life improvement was also considered, the expected savings rise to US$ 102,000. These results imply that increasing donation rate by 1 donor per million population would achieve an estimated cost saving of US$827,000 per year, or near US$3 million per year considering the effect on the quality of life.

Conclusion

These results demonstrated that kidney transplantation along with a better quality of life for patients are a cost-saving decision for developing countries.     

More donors or more delayed graft function? A cost‐effectiveness analysis of DCD kidney transplantation

Expansion of the donor pool with expanded criteria donors and donation after cardiac death (DCD) donors is essential. DCD grafts result in increased rates of primary non‐function (PNF) and delayed graft function (DGF). However, long‐term patient and graft survival is similar between donation after brain death (DBD) donors and DCD donors. The aim of this study was to evaluate the cost‐effectiveness of the use of DCD donors. A Markov‐based decision analytic model was created to simulate outcomes for two wait list strategies: (i) wait list composed of only DBD organs and (ii) wait list combining DBD and DCD organs. Baseline values and ranges were determined from the Scientific Registry of Transplant Recipients (SRTR) database and literature review. Sensitivity analyses were conducted to test model strength and parameter variability. The wait list strategy consisting of DBD donors only provided recipients 5.4 Quality‐adjusted life years (QALYs) at $65 000/QALY, whereas a wait list strategy combining DBD + DCD donors provided recipients 6.0 QALYs at a cost of $56 000/QALY. Wait lists with DCD donors provide adequate long‐term survival despite more DGF. This equates to an improvement in quality of life and decreased cost when compared to remaining on dialysis for any period of time.     

A health‐economic analysis of porcine islet xenotransplantation

Beckwith J, Nyman JA, Flanagan B, Schrover R, Schuurman H‐J. A health‐economic analysis of porcine islet xenotransplantation. Xenotransplantation 2010; 17: 233–242. © 2010 John Wiley & Sons A/S. Abstract: Background: Islet cell transplantation is a promising treatment for type 1 diabetes. To overcome the shortage of deceased human pancreas donors, porcine islet cell xenotransplantation is being developed as an alternative to allotransplantation. The objective of this study was to perform a cost‐effectiveness analysis of porcine islet transplantation in comparison with standard insulin therapy. The patient population for this study was young adults, ages 20 to 40, for whom standard medical care is inadequate in controlling blood glucose levels (hypoglycemia unawareness). Since trial data were lacking, estimates used extrapolations from data found in the literature and ongoing trials in clinical allotransplantation. Cost estimates were based on the data available in the USA. Methods: Markov modeling and Monte Carlo simulations using software specifically developed for health‐economic evaluations were used. Outcomes data for ongoing clinical islet allotransplantation from the University of Minnesota were used, along with probabilities of complications from the Diabetes Control and Complications Trial. Quality‐adjusted life years (QALYs) were the effectiveness measure. The upper limit of being cost‐effective is $100 000 per QALY. Cost data from the literature were used and adjusted to 2007 US dollars using the medical care portion of the Consumer Price Index. Results: In both Markov modeling and Monte Carlo simulations, porcine islet xenotransplantation was both more effective and less costly over the course of the 20‐yr model. For standard insulin therapy, cumulative cost per patient was $661 000, while cumulative effectiveness was 9.4 QALYs, for a cost of $71 100 per QALY. Transplantation had a cumulative cost of $659 000 per patient, a cumulative effectiveness of 10.9 QALYs, and a cost per QALY of $60 700. Islet transplantation became cost‐effective at 4 yr after transplantation, and was more cost‐effective than standard insulin treatment at 14 yr. These findings are related to relative high costs in the transplantation arm of the evaluation during the first years while those in the insulin arm became higher later in follow‐up. Throughout the follow‐up period, effectiveness of transplantation was higher than that of insulin treatment. In sensitivity analysis, duplication or triplication of one‐time initial costs such as costs of donor animal, islet manufacturing and transplantation had no effect on long‐term outcome in terms of cost‐saving or cost‐effectiveness, but the outcome of transplantation in terms of diabetes complications in cases with partial graft function could affect cost‐saving and cost‐effectiveness conclusions. Conclusion: Despite limitations in the model and lack of trial data, and under the assumption that islet transplantation outcomes for young adult type 1 diabetes patients are not dependent on the source of islet cells, this health‐economic evaluation suggests that porcine islet cell xenotransplantation may prove to be a cost‐effective and possibly cost‐saving procedure for type 1 diabetes compared to standard management.     

A cost–utility analysis of treatment options for inguinal hernia in 1,513,008 adult patients

Background: The controversial issue of the cost-effectiveness of laparoscopic inguinal hernia repair is examined, employing a decision analytic method. Materials and methods: The NSAS, NHDS (National Center for Health Statistics), HCUP-NIS (Agency for Healthcare Research and Quality) databases and 51 randomized controlled trials were analyzed. The study group constituted of a total of 1,513,008 hernia repairs. Projection of the clinical, economic, and quality-of-life outcomes expected from the different treatment options was done by using a Markov Monte Carlo decision model. Two logistic regression models were used to predict the probability of hospital admission after an ambulatory procedure and the probability of death after inguinal hernia repair. Four treatment strategies were modeled: (1) laparoscopic repair (LR), (2) open mesh (OM), (3) open non-mesh (ONM), and (4) expectant management. Costs were expressed in US dollars and effectiveness in quality-adjusted life years (QALYs). The main outcome measures were the average and the incremental cost-effectiveness (ICER) ratios. Results: Compared to the expectant management, the incremental cost per QALY gained was $605 ($4086, 9.04 QALYs) for LR, $697 ($4290, 8.975 QALYs) for OM, and $1711 ($6200, 8.546 QALYs) for ONM. In sensitivity analysis the two major components that affect the cost-effectiveness ratio of the different types of repair were the ambulatory facility cost and the recurrence rate. At a LR ambulatory facility cost of $5526 the ICER of LR compared to OM surpasses the threshold of $50,000/QALY. Conclusions: On the basis of our assumptions this mathematical model shows that from a societal perspective laparoscopic approach can be a cost-effective treatment option for inguinal hernia repair.     

Allocation and matching in kidney exchange programs

Living donor kidney transplantation is the preferred treatment for patients suffering from end‐stage renal disease. To alleviate the shortage of kidney donors, many advances have been made to improve the utilization of living donors deemed incompatible with their intended recipient. The most prominent of these advances is kidney paired donation (KPD), which matches incompatible patient–donor pairs to facilitate a kidney exchange. This review discusses the various approaches to matching and allocation in KPD. In particular, it focuses on the underlying principles of matching and allocation approaches, the combination of KPD with other strategies such as ABO incompatible transplantation, the organization of KPD, and important future challenges. As the transplant community strives to balance quantity and equity of transplants to achieve the best possible outcomes, determining the right long‐term allocation strategy becomes increasingly important. In this light, challenges include making full use of the various modalities that are now available through integrated and optimized matching software, encouragement of transplant centers to fully participate, improving transplant rates by focusing on the expected long‐run number of transplants, and selecting uniform allocation criteria to facilitate international pools.     

Cost‐Effectiveness of Hypothermic Machine Preservation Versus Static Cold Storage in Renal Transplantation

Static cold storage (CS) is the most widely used organ preservation method for deceased donor kidney grafts but there is increasing evidence that hypothermic machine perfusion (MP) may result in better outcome after transplantation. We performed an economic evaluation of MP versus CS alongside a multicenter RCT investigating short‐ and long‐term cost‐effectiveness. Three hundred thirty‐six consecutive kidney pairs were included, one of which was assigned to MP and one to CS. The economic evaluation combined the short‐term results based on the empirical data from the study with a Markov model with a 10‐year time horizon. Direct medical costs of hospital stay, dialysis treatment, and complications were included. Data regarding long‐term survival, quality of life, and long‐term costs were derived from literature. The short‐term evaluation showed that MP reduced the risk of delayed graft function and graft failure at lower costs than CS. The Markov model revealed cost savings of $86 750 per life‐year gained in favor of MP. The corresponding incremental cost‐utility ratio was minus $496 223 per quality‐adjusted life‐year (QALY) gained. We conclude that life‐years and QALYs can be gained while reducing costs at the same time, when kidneys are preserved by MP instead of CS.     

Cost-effectiveness of different screening strategies for abdominal aortic aneurysm

OBJECTIVE: The primary objective of this study was to develop a simulation model to assess the cost-effectiveness of different screening strategies for abdominal aortic aneurysms (AAAs) in men. METHODS: A systematic review of the literature was conducted for different screening strategies in terms of age (60, 65, or 70 years) and risk profiles (all men or specific high-risk groups) of the screened population, and rescreening after 5 or 10 years. These data were analyzed in a Markov simulation cohort model. RESULTS: The cost per life year gained for different screening strategies ranged from US 8,309 dollars to US 14,084 dollars and was estimated at US 10,474 dollars when 65-year-old men were screened once. Screening 60-year-old men was equally cost-effective, with the advantage of more life years gained. We demonstrated a trade-off between high prevalence of AAA and lower life expectancy, eliminating the expected benefits of screening high-risk groups such as smokers (US 10,695 dollars) or cardiovascular patients (US 10,392 dollars). Assuming general population utility resulted in a cost per quality-adjusted life year (QALY) gained of US 13,900 dollars, whereas a hypothetical 5% reduction in utility among men with a screening-detected AAA raised the cost per QALY gained to US 75,100 dollars. CONCLUSION: This Markov model, which was based on a systematic review of the literature, supplied information on the estimated cost-effectiveness of different screening strategies. Screening men for AAA may be cost-effective in the long-term. Different screening strategies and quality-of-life effects related to screening for AAA need to be evaluated in future clinical studies.     

A Cost-Effectiveness Analysis of Organ Preservation Methods for Deceased Donor Kidneys at High Risk for Delayed Graft Function in Brazil

The clinical benefit of machine perfusion (MP) was recently assessed in a 1-year Brazilian multicenter prospective randomized trial, that showed that the use of MP was associated with a reduced incidence of delayed graft function (DGF) compared to static cold storage (SCS) in kidney transplant recipients (45% vs 61%). The objective of the present analysis is to consider the cost-effectiveness of MP relative to SCS based on clinical data from this Brazilian cohort. A decision tree model was constructed to simulate a population of 1000 kidney transplant recipients based on data derived from this Brazilian multicenter clinical trial. The model accounts for different health state utilities to estimate the cost-effectiveness of deceased donor kidney transplantation in Brazil comparing 2 kidney preservation methods: MP and SCS. The model accounts for 3 possible graft outcomes at 1 year post-transplantation: success (an immediate functioning kidney), failure (primary nonfunction requiring a return to dialysis), or DGF 1 year post-transplant. MP provided 612 total quality-adjusted life years (QALYs) (0.61 QALYs per patient) as compared to SCS (553 total QALYs, 0.55 QALYs per patient). MP was cost effective relative to SCS (US$22,117/QALY, R$70,606/QALY). The use of MP also resulted in more functioning grafts than SCS (821 vs 787), leading to a cost per functioning graft of US$38,033 (R$121,417). In conclusion, this analysis indicates that, despite the initial added cost associated with MP, the use of MP results in more functioning grafts (821 vs 787) and higher patient quality of life relative to SCS in Brazil.     

Can donors with high donor risk indices be used cost‐effectively in liver transplantation in US Transplant Centers?

In an effort to quantify the impact of donor risk factors on recipient outcomes, the donor risk index (DRI) was developed. A high DRI correlates with poorer post‐transplant survival. In this study, high‐DRI donors are classified as those having DRIs >2.0, while low‐DRI donors have DRIs <2.0. The aim of this study was to evaluate the cost‐effectiveness of high‐DRI donor use in US Transplant Centers. A Markov‐based decision analytic model was created to simulate outcomes for an allocation scheme using only low‐DRI donors versus a scheme using both low‐ and high‐DRI donors. Baseline values and ranges were determined from published data and Medicare cost data. Sensitivity analyses were conducted to test model strength and parameter variability. An allocation scheme in which only low‐DRI donors were used generated 5.2 quality‐adjusted life years (QALYs) at a cost of $83 000/QALY. An allocation scheme using both low‐ and high‐DRI donors generated 5.9 QALYs at a cost of $66 000/QALY. Sensitivity analyses supported the use of an allocation scheme using both low‐ and high‐DRI donors. The overall contribution of high‐DRI grafts to the donor pool and the resultant reduction in wait‐list mortality make them cost‐effective.     

Screening to Prevent Polyoma Virus Nephropathy: A Medical Decision Analysis

Polyomavirus nephropathy (PVN) is an emerging medical dilemma in kidney transplantation. Methods to screen before clinical disease are available and early immunosuppression reduction may change the natural history of progression. However, the consequences of an increase in rejection may limit the benefits. In a simulation model a 'screen' versus 'no-screen' strategy was compared. Baseline PVN cumulative incidence was assumed to be 4%. Patients with PVN were modeled to have 4-fold higher risk of graft loss. In the screen strategy, patients positive for blood DNA PCR had their immunosuppression reduced. This pre-emptive change was modeled to reduce progression to overt PVN by 80%. Therapy reduction was associated with a 10% risk of precipitating acute rejection and greater risk of chronic allograft loss. In the baseline case, screening saved 1912 dollars (discounted) and produced 0.020 more quality adjusted life years (QALYs) than not screening. Screening resulted in decreased net QALYs if the false positive viremia rate was >9.5% and the PVN incidence was <2.1%. Much of the cost savings of screening relate to savings from immunosuppression reduction in the screened arm. Screening may well be cost-effective if not cost saving in centers with high PVN rates. There remain significant areas of uncertainty.