Normothermic perfusion can save nearly $1 billion over cold storage for liver transplant

Adding normothermic machine perfusion to an existing liver transplant program would add quality adjusted life years while saving money and proving cost effective, according to a presentation at The Liver Meeting Digital Experience.

“Over the last decade, the number of liver grafts available for transplantation in Canada decreased from 83% down to 60%. This has led to an increase in our waitlist mortalities from 22% up to 26%,” Alexandria N. Webb, MD, of the University of Alberta, Canada, said during her presentation. “To help bridge the supply and demand gap that we have, we started using an increased number of extended criteria grafts. This includes liver grafts that are coming from people who have fatty liver disease, are older adults, have abnormal liver enzymes or are unstable in the ICU prior to procurement. Because of this, these extended criteria grafts are more susceptible to the static cold storage process that leads to increased complications post transplantation for our recipients. We also know that transplantation teams are very busy and this puts them at risk for clinical team burnout.”

Webb and colleagues designed a Markov model in which they compared two strategies: the status quo of cold static storage as the transplant option vs. using normothermic machine perfusion (NMP) in addition to cold static storage as an option for transplant. They compared them over a year’s time. Researchers applied micro-costing data from a single center retrospective trial and utility values from the literature.

“Normothermic machine perfusion allows for safe use of extended criteria grafts and grafts that would otherwise not be transplanted,” Webb said, explaining that the NMP perfuses the graft at normal physiologic levels and allows assessment of synthetic and metabolic viability.

After modeling, the cumulative costs for NMP were $5.57 billion CAD while the control was $6.39 billion CAD. The mean cost of NMP was $557,450 CAD vs. the control’s $634,106. Over the estimated 5 years, NMP showed 3.48 QALY vs. the control’s 3.17 QALYs.

“This shows that the NMP strategy is actually cost saving,” Webb said.

In a probability scenario analysis, Webb showed that NMP was cost effective 63% of the time when considering a conventional willingness to pay threshold of $50,000 CAD.

“No matter what the willingness to pay is, from $0 up to $100,000, the NMP strategy is always more cost effective in relation to the static cold storage strategy,” she said.

With the knowledge that NMP would allow for transplantation for more patients, therefore decreasing the waitlist mortality and the number of people on the waitlist where costs are high for the patient, Webb concluded NMP would be cost effective to add to existing liver transplant programs.

“Additionally, if we expanded our perspective from the public health care payer perspective to include the societal perspective, we’d likely find it has even more economic value,” she said. “The societal perspective includes burnout from the physician team as well as other care providers, it includes accommodation and travel if someone has to go to another center for their transplant, as well as work productivity losses for both the patient and their informal caregivers. Additionally, we know that adding NMP in can transition transplantations from nighttime to daytime where the premium costs of working overnight can add to the overall costs and this also has impacts on cost of burnout for the physician teams.”