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Influence of heart transplant allocation changes on hospital resource utilization
Robert B Hawkins1, Erik Scott2, J Hunter Mehaffey2
1Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
Insights
The 2018 heart transplant allocation changes increased temporary mechanical circulatory support use. This led to longer preoperative stays but did not significantly impact overall hospital costs.
Area of Science:
- Cardiology
- Transplantation Medicine
- Health Services Research
Background:
- The 2018 heart transplant allocation system revision aimed to improve organ distribution.
- This change potentially influenced patient management strategies, including the use of mechanical circulatory support.
- Understanding the impact on hospital resources is crucial for healthcare planning.
Purpose of the Study:
- To evaluate the effect of the 2018 heart transplant allocation system change on hospital resource utilization.
- To assess changes in length of stay and total hospital costs post-allocation reform.
- To identify factors driving resource utilization in heart transplant recipients.
Main Methods:
- Retrospective analysis of heart transplant patients from a Society of Thoracic Surgeons database (2012-2020).
- Stratification into pre-reform (early) and post-reform (late) eras.
- Cost data adjusted for inflation; multivariable regression used to identify resource utilization drivers.
Main Results:
- The late era saw increased use of temporary mechanical circulatory support (4% to 46%) and decreased use of durable left ventricular assist devices.
- Preoperative length of stay significantly increased in the late era (1 to 9 days).
- No significant difference in total hospital costs was observed between the early and late eras, despite high variability.
Conclusions:
- The 2018 allocation system shift led to greater reliance on temporary mechanical circulatory support.
- Increased preoperative length of stay was associated with the new allocation system.
- Despite changes in bridging strategies, the reform did not result in increased overall hospital costs.
Objectives:
The 2018 change in the heart transplant allocation system resulted in greater use of temporary mechanical circulatory support. We hypothesized that the allocation change has increased hospital resource utilization, including length of stay and cost.
Methods:
All heart transplant patients within a regional Society of Thoracic Surgeons database were included (2012-2020). Patients were stratified before and after the transplant allocation changes into early (January 2012-September 2018) and late eras (November 2018-June 2020). Costs were adjusted for inflation and presented in 2020 dollars.
Results:
Of 535 heart transplants, there were 410 early and 125 late era patients. Baseline characteristics were similar, except for greater lung and valvular disease in the late era. Fewer patients in the late era were bridged with durable left ventricular assist devices (69% vs 31%; P < .0001), biventricular devices (5% vs 1%; P = .047), and more with temporary mechanical circulatory support (4% vs 46%; P < .0001). There was no difference in early mortality (6% vs 4%; P = .33) or major morbidity (57% vs 61%; P = .40). Length of stay was longer preoperatively (1 vs 9 days; P < .0001), but not different postoperatively. There was no difference in median total hospital cost ($132,465 vs $128,996; P = .15), although there was high variability. On multivariable regression, preoperative extracorporeal membrane oxygenation utilization was the main driver of resource utilization.
Conclusions:
The new heart transplant allocation system has resulted in different bridging techniques, with greater reliance on temporary mechanical circulatory support. Although this is associated with an increase in preoperative length of stay, it did not translate into increased hospital cost.
