Variation in the Incidence Biliary Complications in Liver Transplantation: Outcome and Economic Implications.

Abstract

Background: Despite improvement in patient and graft outcomes following liver transplantation (LT), biliary complications (BC) remain a significant source of morbidity and expense. Using a novel data base linking OPTN registry data and Medicare claims, we report a national assessment of variation in the incidence of BC in transplant centers (TC) using brain dead (DBD) and cardiac death (DCD) donors. Methods: 16,286 LTs performed from 2002-8 were analyzed to identify BC, defined as having both a diagnosis (leak, stricture, cholangitis) and a procedure (IR, ERCP, surgery) for BC. Multivariate logistic models calculated the TC’s expected incidence of BC given donor and recipient factors. TCs observed to expected (O:E) ratios were calculated separately for DCD and DBD transplantation, assigned to quartiles, and correlated with clinical and financial outcomes Results: The incidence of BC varied widely between TC for both DBD (N=104 TCs) and DCD (N=42 TCs). BC following DBD LT ranged from 70% less than expected (O:E 0.3) to 1100% higher than expected (O:E: 11) which was greater than the range for DCDs (O:E 0.42-9.0). TCs with greater O:E ratios for BC in both DBD and DCD LT actually used lower risk organs and had similar MELD scores (table).Table: No Caption available.LT in TCs with the highest adjusted rates of BC was associated with increased post-transplant mortality after DCDs (Q4 vs Q1: OR 2.75 P<.001) and graft loss in DBDs (Q4 vs Q1 OR 1.2 p<.05). Incremental Medicare spending was $22,367 (p<.05) higher in TCs in the highest quartile of BC complications (DBD/DCD combined). Conclusion: The incidence of post-operative BC varies substantially across TCs nationally. High O:E ratios of BC are associated with higher graft loss, patient death, and Medicare spending.