OPTN/SRTR 2019 Annual Data Report: Economics

Abstract

Resource utilization metrics vary widely across solid organ transplant modalities. Average length of stay (LOS) for kidney transplant has declined by 15.1%, from 8.7 days in 2008 to 7.4 days in 2019. A similar decline in LOS of 17.5% was seen in pancreas transplant. LOS for liver transplant remained relatively stable over this period, while LOS was most variable for intestine transplant, with a high of 70.9 days in 2008 and 26.2% lower (52.3 days) in 2011. However, LOS for both heart and lung transplant have generally risen through 2019. Pediatric patients generally experienced the longest LOS across all organs. Large variation in LOS by diagnosis was seen across organs, with the shortest LOS in kidney for glomerulonephritis, liver for hepatocellular carcinoma, and lung for obstructive pulmonary disease. Reported readmission during the first year post-transplant in 2018 varied from a low of 39.9% in heart, followed by 48.1% in kidney, 52.1% in lung, 59.7% in liver, and 61.8% in pancreas, to a high of 95.6% in intestine. In kidney, liver, and heart transplant, Asian recipients had the fewest readmissions across all years.

Introduction

With this Annual Data Report, SRTR is providing new resource utilization metrics to support health economics, financial analysis, and cost-effectiveness modeling in solid organ transplantation. The metrics presented include length of stay (LOS) during the transplant hospitalization, rehospitalization in the first year post-transplant, and the relationship between LOS, rehospitalization, and patient characteristics. The LOS metric is the number of days from admission to discharge, which includes in-hospital days before transplant, if it is the same admission. We expect to continue to expand the development and presentation of new health economic, financial, and resource utilization metrics in future reports.

Kidney

LOS for the kidney transplant hospitalization has shown a general decline between 2008 and 2019, with year-over-year declines in most years (Figure ECON 1). Average LOS was 8.7 days in 2008 and 7.4 days in 2019, a decline of 1.3 days (15.1%). Transplant LOS was shorter for younger adult patients ages 18-34 and 35-49 (Figure ECON 2). However, pediatric patients younger than 18 had the longest LOS, and while adult LOS has been declining, pediatric LOS has risen from an average of 11.9 days in 2008 to 13.1 days in 2019, an increase of 1.2 days (10.4%). In contrast, over the same period, transplant LOS has declined by 20.3% for those 18 to 34 years, 20.2% for those 35 to 49, 13.9% for those 50 to 64, and 14.1% for those 65 and older at transplant. There has been little difference in the change in LOS by sex, with a 14.0% decline for males and a 16.9% decline for females (Figure ECON 3).

Average transplant LOS in 2019 was shortest for Asian recipients (6.6 days) and longest for Black recipients (7.8 days), compared with other race and ethnicity categories. However, very little difference in the change in LOS since 2008 was observed, with changes ranging from a 15.6% decline in Hispanic recipients to a 14.6% decline in Black recipients (Figure ECON 4). Transplant LOS was shortest in 2019 for recipients with a primary diagnosis of glomerulonephritis (6.0 days), followed by hypertension (6.3 days), cystic kidney disease (6.4 days), diabetes (7.5 days), and other or unknown disease, which includes tubular, interstitial, and congenital diseases and cases in which no UNOS diagnosis code was given but the diagnosis was written out with text or the diagnosis was indicated as unknown (10.3 days) (Figure ECON 5). Declines in transplant LOS by diagnosis from 2008 to 2019 ranged from 24.1% for hypertension to 17.5% for cystic kidney disease, with the exception of other or unknown diagnosis, which saw a slight increase of 1.7%.

Among those who underwent kidney transplant in 2018, recipients alive with a functioning graft 1 year post-transplant had the shortest average transplant LOS (7.4 days), compared with those whose grafts failed in the first year (11.3 days) and those who died (17.5 days) (Figure ECON 6). Similarly, 2-year outcome correlates with transplant LOS, with the shortest LOS in patients alive with function at year two (7.4 days), followed by patients experiencing graft failure by year two (11.2 days), and death (15.8 days) (Figure ECON 7).

Numbers of patients with one or more hospital readmissions within the first year after kidney transplant have risen sharply in the past several years, with a 5.4% absolute and 12.7% relative rise from 2013 to 2018, up from 42.6% to 48.1% of patients readmitted (Figure ECON 8). Among those who underwent kidney transplant in 2018, pediatric recipients were most frequently readmitted in the first year (62.2%), compared with adults aged 35 to 49, who had the lowest readmission rate (44.2%) (Figure ECON 9). Female recipients were more frequently readmitted (50.6%) than males (46.4%) (Figure ECON 10). Asian recipients were the least commonly readmitted (42.7%) (Figure ECON 11). The readmission rate for patients who underwent transplant in 2018 was lowest for those diagnosed with glomerulonephritis (41.0%), followed by hypertension (44.5%), cystic kidney disease (45.6%), other or unknown diagnosis (51.8%), and diabetes (53.4%) (Figure ECON 12).

Pancreas

Average LOS for pancreas transplant hospitalization in 2019 was the lowest since 2008 (Figure ECON 13). Average LOS was 14.0 days in 2008 and 11.5 days in 2019, a decline of 2.5 days (17.5%). LOS for pancreas transplant varied little by age (Figure ECON 14) or sex (Figure ECON 15).

Among those who underwent pancreas transplant in 2018, recipients who were alive 1 year post-transplant had shorter average transplant LOS (11.1 days) than those who died within the first year (37.6 days) (Figure ECON 18). This pattern repeats when transplant LOS is compared by 2-year survival status, with shorter LOS in patients who were alive at year two (11.5 days) than those who died within 2 years (28.9days) (Figure ECON 19). In 2019, pancreas-alone recipients had longer average transplant LOS (23.1 days) than recipients of simultaneous kidney-pancreas (10.6 days) and pancreas after kidney (8.8 days) (Figure ECON 20).

Rehospitalization in the first year post-transplant for pancreas recipients fell from a high of 64.1% among those who underwent transplant in 2009 to 56.6% among those who underwent transplant in 2015 before rising to 61.8% among those who underwent transplant in 2018 (Figure ECON 21). Among those who underwent transplant in 2018, young adult (ages 18 to 34) pancreas recipients generally had higher readmission rates (64.2%) than those aged 35 to 49 (61.8%) and those aged 50 and older (59.7%) (Figure ECON 22). Female pancreas recipients were more frequently readmitted (66.3%) than males (58.8%) (Figure ECON 23).

Liver

LOS for liver transplantation was remarkably stable between 2008 and 2019, varying no more than 10% across the years (Figure ECON 27). The longest average LOS was 23.0 days, in 2015, and the shortest was 20.8 days, in 2019, a difference of 9.6%. Transplant LOS was longest for pediatric patients younger than 18, (34.5 days in 2019) (Figure ECON 28). While there was some variation in LOS by age-group over the years, in 2019, LOS declined with age across the groups, at 24.5 days for those aged 18 to 34, 21.5 days for ages 35 to 49, 19.6 days for ages 50 to 64, and 18.1 days for ages 65 and older. Female liver recipients had longer LOS in all years, at 22.1 days for females and 20.1 days for males in 2019 (Figure ECON 29). White and Asian liver recipients had consistently shorter LOS than Hispanic recipients across all years, and LOS was variable for Black and other races (Figure ECON 30). Large differences in transplant LOS were observed by primary cause of liver disease (Figure ECON 31). Recipients with hepatocellular carcinoma (HCC) experienced the shortest LOS in 2019 (13.6 days), followed by HCV (19.1 days), alcoholic liver disease (21.3 days), cholestatic disease (22.5 days), other or unknown (22.7 days), and acute liver failure (26.2 days).

Among those who underwent liver transplant in 2018, recipients alive with a functioning graft 1 year post-transplant had the shortest average transplant LOS (20.4 days), compared with those within whose grafts failed in the first year (37.1 days) and those who died (37.9 days) (Figure ECON 32). Two-year outcome had a similar relationship with LOS (Figure ECON 33), with the shortest LOS in patients alive with function at year two (19.5 days), followed by patients who died (32.0 days) and those experiencing graft failure by year two (33.4 days).

The number of patients with hospital readmission in the first year after liver transplant was relatively stable among recipients from 2008 to 2018. The lowest proportion of patients readmitted was 56.6%, among those who underwent transplant in 2015, compared with 59.8% among 2017 recipients, a relative difference of 5.8% (Figure ECON 34). Among those who underwent liver transplant in 2018, pediatric recipients were most frequently readmitted in the first year (70.5%), followed by recipients age 18 to 34 (65.8%) and similar readmission rates in older recipients, 35 to 49 (58.8%), 50 to 64 (57.9%), and 65 and older (59.2%) (Figure ECON 35). Female recipients were more frequently readmitted than male recipients (Figure ECON 36). The difference varied from 58.0% versus 60.0% among those who underwent transplant in 2011, a 3.5% relative difference, to 55.2% versus 61.1% among those who underwent transplant in 2016, a 10.7% relative difference. Asian recipients were the least frequently readmitted for all years (43.3% to 52.6%), while Hispanic recipients were more frequently readmitted than white recipients in each year, with Black and other races varying by year (Figure ECON 37). Readmission by primary diagnosis of liver disease was variable. Generally, HCC patients were least commonly readmitted (53.2% among those who underwent transplant in 2018), while those with and cholestatic disease (62.1%) and acute liver failure (61.6%) were most commonly readmitted (Figure ECON 38).

Intestine

LOS for intestine transplantation varied from a high of 70.9 days in 2008 to a low of 52.3 days in 2011, 26.2% lower (Figure ECON 39). Transplant LOS was longer for pediatric patients younger than 18 (84.1 days in 2019) than for adults (47.0 days in 2019) (Figure ECON 40). Patients with congenital short gut syndrome or necrotizing enterocolitis had consistently longer LOS than those with non-congenital SGS from 2008 to 2019 (Figure ECON 43). No consistent patterns in LOS were observed by sex (Figure ECON 41) or race (Figure ECON 42).

Among those who underwent intestine transplant in 2018, recipients alive with a functioning graft 1 year post-transplant generally had the shortest average transplant LOS (60.5 days), compared with those whose grafts failed within the first year (64.3 days) and those who died (100.0 days) (Figure ECON 44). The pattern for 2-year outcome was less apparent among alive, dead, and surviving graft failure (Figure ECON 45).

Among intestine recipients from 2008 to 2018, the vast majority were readmitted at least once in the first year post-transplant (92.8% to 97.6%, Figure ECON 46). There were little, if any, discernable differences in readmission in the year after intestine transplant by age (Figure ECON 47), sex (Figure ECON 48), race (Figure ECON 49), or diagnosis (Figure ECON 50).

Heart

Average LOS for heart transplantation has risen 21.3%, from a low of 40.6 days in 2010 to a high of 49.2 days in 2019 (Figure ECON 51). Among those who underwent transplant in 2019, pediatric recipients younger than 18 had the longest average transplant LOS (90.6 days), while recipients older than 65 generally had the shortest transplant LOS (40.3 days in 2019) (Figure ECON 52). Pediatric patients had the largest increase in LOS, at 40.2% from 2008 to 2019. Female heart recipients had longer LOS in all years, 52.0 days for females and 47.9 days for males, in 2019 (Figure ECON 53). White, Asian, and Black heart recipients had similar LOS that was generally shorter than that of Hispanic recipients and those of other races (Figure ECON 54). Patients with primary diagnoses of coronary artery disease, cardiomyopathy, and valvular disease generally had similar LOS, which was much lower than patients with congenital disease (Figure ECON 55).

Among those who underwent heart transplant in 2018, recipients alive with a functioning graft 1 year post-transplant had the shortest average LOS (47.3 days), compared with those whose grafts failed within the first year (52.2 days) or died (71.8 days) (Figure ECON 56). Two-year outcome had a similar relationship with LOS (Figure ECON 57), in which the shortest LOS was observed in patients alive with function at year two (45.4 days), followed by patients who died (62.1 days) and those experiencing graft failure by year two (69.4 days). Death-censored graft failure (retransplant) is relatively uncommon among heart transplant recipients, so the data by graft failure outcome varied more by year than did the data by vital status.

Readmission in the first year after heart transplant varied from a low of 34.6% among those who underwent transplant in 2010 to a high of 41.1% among those who did so in 2017 (Figure ECON 58). Over the years, pediatric heart recipients were more frequently readmitted in the first year (46.0% among those who underwent transplant in 2018); however, there were no consistent differences in readmission among the other age groups (Figure ECON 59). Female recipients were more frequently readmitted than male recipients (45.2% of females vs 37.6% of males) among those who underwent transplant in 2018 (Figure ECON 60). Asian recipients were the least frequently readmitted (30.5%); however, there were no consistent differences in readmission rates among other races and ethnicity groups (Figure ECON 61). Readmission was generally more common in patients with a congenital primary diagnosis (Figure ECON 62).

Lung

Average LOS for lung transplant has risen 28.5%, from a low of 27.9 days in 2012 to a high of 35.9 days in 2018 (Figure ECON 63). Pediatric recipients younger than 18 had the longest average transplant LOS in all years but 2017 (52.0 days in 2019), while recipients older than 65, as well as those aged 50 to 64, had the shortest LOS across the years (29.4 and 35.0 days in 2019, respectively) (Figure ECON 64). The largest increase in LOS between 2008 and 2019 was seen in the 50-to-64 age-group, an increase of 32.8%. Female heart recipients generally had longer LOS than males (Figure ECON 75). Asian and Black lung recipients generally had higher LOS than recipients of other races (Figure ECON 66). Primary diagnosis was one of the strongest stratifiers of LOS in lung recipients (Figure ECON 67). The shortest LOS across all years was observed in LAS diagnostic group A (obstructive) (28.5 days in 2019), group C (cystic fibrosis), and group D (restrictive) were similar (34.2 and 36.1 days, respectively, in 2019), and group B (pulmonary vascular) had the longest average LOS across all years (41.8 days in 2019).

Among those who underwent lung transplant in 2018, recipients alive with a functioning graft 1 year post-transplant had the shortest average transplant LOS (32.8 days), compared with those whose grafts failed within the first year or died (52.6 and 60.8 days, respectively) (Figure ECON 68). Recipients alive with a functioning graft 2 years post-transplant had the shortest average transplant LOS across all years (28.5 days), compared with those whose grafts failed within the second year or died (68.5 and 54.1 days, respectively) (Figure ECON 69). Similarly to heart transplant, death-censored graft failure (retransplant) is relatively uncommon among lung transplant recipients, so the data by graft failure outcome varied more by year than did the data by vital status.

Readmission within the first year after lung transplant fell 22.4%, from 57.3% among those who underwent transplant in 2008, to 44.4% among those who underwent transplant in 2015, and then rose 17.3% to 52.1% among those who underwent transplant in 2018 (Figure ECON 70). Discernable differences in readmission patterns were not observed by age (Figure ECON 71), sex (Figure ECON 72), race (Figure ECON 73), or diagnosis (Figure ECON 74).

Figure List

ECON

Figure ECON 1. Overall average number of days in hospital during kidney transplant admission
Figure ECON 2. Average number of days in hospital during kidney transplant admission by age
Figure ECON 3. Average number of days in hospital during kidney transplant admission by sex
Figure ECON 4. Average number of days in hospital during kidney transplant admission by race/ethnicity
Figure ECON 5. Average number of days in hospital during kidney transplant admission by diagnosis
Figure ECON 6. Average number of days in hospital during kidney transplant admission by one year patient outcome
Figure ECON 7. Average number of days in hospital during kidney transplant admission by two year patient outcome
Figure ECON 8. Overall percent of kidney transplant recipients rehospitalized in the first year after transplant
Figure ECON 9. Percent of kidney transplant recipients rehospitalized in the first year after transplant by age
Figure ECON 10. Percent of kidney transplant recipients rehospitalized in the first year after transplant by sex
Figure ECON 11. Percent of kidney transplant recipients rehospitalized in the first year after transplant by race/ethnicity
Figure ECON 12. Percent of kidney transplant recipients rehospitalized in the first year after transplant by diagnosis
Figure ECON 13. Overall average number of days in hospital during pancreas transplant admission
Figure ECON 14. Average number of days in hospital during pancreas transplant admission by age
Figure ECON 15. Average number of days in hospital during pancreas transplant admission by sex
Figure ECON 16. Average number of days in hospital during pancreas transplant admission by race/ethnicity
Figure ECON 17. Average number of days in hospital during pancreas transplant admission by diagnosis
Figure ECON 18. Average number of days in hospital during pancreas transplant admission one year patient outcome
Figure ECON 19. Average number of days in hospital during pancreas transplant admission by two year patient outcome
Figure ECON 20. Average number of days in hospital during pancreas transplant admission by pancreas transplant type
Figure ECON 21. Overall percent of pancreas transplant recipients rehospitalized in the first year after transplant
Figure ECON 22. Percent of pancreas transplant recipients rehospitalized in the first year after transplant by age
Figure ECON 23. Percent of pancreas transplant recipients rehospitalized in the first year after transplant by sex
Figure ECON 24. Percent of pancreas transplant recipients rehospitalized in the first year after transplant by race/ethnicity
Figure ECON 25. Percent of pancreas transplant recipients rehospitalized in the first year after transplant by diagnosis
Figure ECON 26. Percent of pancreas transplant recipients rehospitalized in the first year after transplant by pancreas transplant type
Figure ECON 27. Overall average number of days in hospital during liver transplant admission
Figure ECON 28. Average number of days in hospital during liver transplant admission by age
Figure ECON 29. Average number of days in hospital during liver transplant admission by sex
Figure ECON 30. Average number of days in hospital during liver transplant admission by race/ethnicity
Figure ECON 31. Average number of days in hospital during liver transplant admission by diagnosis
Figure ECON 32. Average number of days in hospital during liver transplant admission by one year patient outcome
Figure ECON 33. Average number of days in hospital during liver transplant admission by two year patient outcome
Figure ECON 34. Overall percent of liver transplant recipients rehospitalized in the first year after transplant
Figure ECON 35. Percent of liver transplant recipients rehospitalized in the first year after transplant by age
Figure ECON 36. Percent of liver transplant recipients rehospitalized in the first year after transplant by sex
Figure ECON 37. Percent of liver transplant recipients rehospitalized in the first year after transplant by race/ethnicity
Figure ECON 38. Percent of liver transplant recipients rehospitalized in the first year after transplant by diagnosis
Figure ECON 39. Overall average number of days in hospital during intestine transplant admission
Figure ECON 40. Average number of days in hospital during intestine transplant admission by age
Figure ECON 41. Average number of days in hospital during intestine transplant admission by sex
Figure ECON 42. Average number of days in hospital during intestine transplant admission by race/ethnicity
Figure ECON 43. Average number of days in hospital during intestine transplant admission by diagnosis
Figure ECON 44. Average number of days in hospital during intestine transplant admission by one year patient outcome
Figure ECON 45. Average number of days in hospital during intestine transplant admission two year patient outcome
Figure ECON 46. Overall percent of intestine transplant recipients rehospitalized in the first year after transplant
Figure ECON 47. Percent of intestine transplant recipients rehospitalized in the first year after transplant by age
Figure ECON 48. Percent of intestine transplant recipients rehospitalized in the first year after transplant by sex
Figure ECON 49. Percent of intestine transplant recipients rehospitalized in the first year after transplant by race/ethnicity
Figure ECON 50. Percent of intestine transplant recipients rehospitalized in the first year after transplant by diagnosis
Figure ECON 51. Overall average number of days in hospital during heart transplant admission
Figure ECON 52. Average number of days in hospital during heart transplant admission by age
Figure ECON 53. Average number of days in hospital during heart transplant admission by sex
Figure ECON 54. Average number of days in hospital during heart transplant admission by race/ethnicity
Figure ECON 55. Average number of days in hospital during heart transplant admission by diagnosis
Figure ECON 56. Average number of days in hospital during heart transplant admission by one year patient outcome
Figure ECON 57. Average number of days in hospital during heart transplant admission by two year patient outcome
Figure ECON 58. Overall percent of heart transplant recipients rehospitalized in the first year after transplant
Figure ECON 59. Percent of heart transplant recipients rehospitalized in the first year after transplant by age
Figure ECON 60. Percent of heart transplant recipients rehospitalized in the first year after transplant by sex
Figure ECON 61. Percent of heart transplant recipients rehospitalized in the first year after transplant by race/ethnicity
Figure ECON 62. Percent of heart transplant recipients rehospitalized in the first year after transplant by diagnosis
Figure ECON 63. Overall average number of days in hospital during lung transplant admission
Figure ECON 64. Average number of days in hospital during lung transplant admission by age
Figure ECON 65. Average number of days in hospital during lung transplant admission by sex
Figure ECON 66. Average number of days in hospital during lung transplant admission by race/ethnicity
Figure ECON 67. Average number of days in hospital during lung transplant admission by diagnosis
Figure ECON 68. Average number of days in hospital during lung transplant admission by one year patient outcome
Figure ECON 69. Average number of days in hospital during lung transplant admission by two year patient outcome
Figure ECON 70. Overall percent of lung transplant recipients rehospitalized in the first year after transplant
Figure ECON 71. Percent of lung transplant recipients rehospitalized in the first year after transplant by age
Figure ECON 72. Percent of lung transplant recipients rehospitalized in the first year after transplant by sex
Figure ECON 73. Percent of lung transplant recipients rehospitalized in the first year after transplant by race/ethnicity
Figure ECON 74. Percent of lung transplant recipients rehospitalized in the first year after transplant by diagnosis