Renal transplantation is the preferred treatment for end stage renal disease because of superior survival and quality of life outcomes compared to dialysis, with reduced cost. Patient outcomes are nevertheless not optimal. End Stage Renal Disease (ESRD) patients have many comorbidities and transplant recipients carry these comorbidity loads. Comorbidity information can be used to examine organ allocation and economic aspects of kidney transplantation.
In this dissertation, three different peer-reviewed articles explored the impact of comorbid disease on kidney organ allocation, economic analysis and health care reimbursement. The first paper determined whether use of a comprehensive array of pre-transplant comorbidities would improve predictions of graft and patient survival that could be applied to improve the benefit derived from organ allocation. Pretransplant comorbidities derived from administrative claims did not identify factors not collected on the nationwide transplant registry with a significant impact on graft outcome predictions. The second paper investigated associations between pre-transplant comorbidities and 3-year Medicare cost in kidney transplant recipients. The comorbidities with the largest impact on mean Medicare payments included cardiovascular disease, malignancies, cerebrovascular disease, mental conditions and functional limitations. Skin ulcers and infections, rheumatic and other connective tissue disease and liver disease also contributed to payments, and have not been considered or described previously. A positive graded relationship was found between costs and number of pre-transplant comorbidities. The third paper investigated associations between pre-transplant comorbidities, length of stay (LOS) and Medicare payments for the transplant hospitalization. Epilepsy, upper respiratory disease, liver disease, peptic ulcer disease and cancer were also associated with increased LOS and payments. Each additional Charlson and Elixhauser comorbidity increased LOS 70-90% more than payments.
This body of research has several implications. An expanded list of pre-transplant comorbidities did not prove useful to expand organ allocation predictive models but provided new knowledge related to post-transplant Medicare cost and could be used to assess more accurately the financial implications of renal transplantation to Medicare and individual transplant centers. Finally, high comorbidity load was associated with inadequate Medicare payments. Adjustment of Medicare reimbursement for transplantation of higher-risk recipients and using non-standard organs warrants consideration.
|Advisor:||Schnitzler, Mark A.|
|Commitee:||Burroughs, Thomas E., Salvalaggio, Paolo R.|
|School:||Saint Louis University|
|Department:||Public Health Studies|
|School Location:||United States -- Missouri|
|Source:||DAI-B 72/03, Dissertation Abstracts International|
|Subjects:||Public health, Health care management|
|Keywords:||Costs, Hospitalization, Kidney transplantation, Organ allocation|
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