Identifying drivers of cost in pediatric Liver Transplantation

Background & Aims Understanding the economics of pediatric liver transplantation (LT) is central to high-value care initiatives. We examined cost and resource utilization in pediatric LT nationally to identify drivers of cost and hospital factors associated with greater total cost of care. Approach & Results We reviewed 3295 children (<21 y) receiving a LT from 2010-2020 in the Pediatric Health Information System to study cost, both per LT and service-line, and associated mortality, complications and resource utilization. To facilitate comparisons, patients were stratified into high-, intermediate-, or low-cost tertiles based on LT cost. The median cost per LT was $150,836 [IQR $104,481-250,129], with marked variance in cost within, and between, hospital tertiles. High-cost hospitals (HCH) cared for more patients with the highest severity of illness, and mortality risk levels (67% and 29%, respectively), compared to intermediate (60%, 21%; p<0.001), and low (51%,16%; p<0.001) cost hospitals. Patients at HCH experienced a higher prevalence of mechanical ventilation, TPN use, renal comorbidities and surgical complications than other tertiles. Clinical (27.5%), Laboratory (15.1%), and Pharmacy (11.9%) service-lines contributed most to total cost. Renal comorbidities ($69,563) and TPN use ($33,192) were large, independent contributors to total cost, irrespective of the cost tertile (p<0.001). Conclusions There exists significant variation in pediatric LT cost, with HCH caring for more patients with higher illness acuity and resource need. Studies are needed to examine drivers of cost and associated outcomes more granularly, with the goal of defining value and standardizing care. Such efforts may uniquely benefit the sicker patients requiring the strategic resources located within HCH to achieve the best outcomes.