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Utilization and Cost Analysis of Lung Transplantation and Survival After 10 Years of Adapting the Lung Allocation Score

Keller, Cesar A., MD1; Gonwa, Thomas A., MD1; White, Launia J., BS2; Rucci, March E., MHA2; Visscher, Sue L., PhD2; Kennedy, Cassie C., MD2,3; Daly, Richard C., MD4; Naessens, James M., SCD2,5

doi: 10.1097/TP.0000000000002227
Original Clinical Science—General

Background. Lungs are allocated in the United States using the lung allocation score (LAS). We investigated the effect of LAS trends on lung transplant-related costs, healthcare utilization, and mortality.

Methods. Utilization data from Mayo Clinic (Florida and Minnesota) from 2005 to 2015 were obtained from the electronic health records (N = 465). Costs were categorized as 1-year posttransplant or transplant episode and standardized using 2015 Medicare reimbursement and cost-to-charge ratios. Regression analysis was used to assess the relationship of LAS to length of stay (LOS), mortality, and cost of transplant.

Results. The mean LAS at transplant increased from 45.7 to 58.3 during the study period, whereas the 1-year survival improved from 88.1% to 92.5% (P < 0.0001). The proportion of patients transplanted with LAS of 60 or greater increased from 16.9% to 33.3%. Posttransplant, overall, and intensive care unit LOS increased with increasing LAS. Patients with higher LAS had substantially higher transplant episode costs. An increase of LAS at transplant by 10 points increased inflation-adjusted costs by 12.0% (95% confidence interval, 9.3%–14.5%).

Conclusions. The mean LAS at transplant has significantly increased over time associated with increases in LOS, resource utilization and cost. Lung allocation score has not jeopardized overall survival, but a high LAS (>60) at transplant is associated with increased mortality.

1Department of Transplantation, Mayo Clinic, Jacksonville, FL.

2Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota and Jacksonville, FL.

3Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.

4Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.

5Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.

Received 6 November 2017. Revision received 28 February 2018.

Accepted 7 March 2018.

This work was supported in part by the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, an unrestricted grant by United Therapeutics and by NHLBI of the NIH under award number K23 HL 128859 (C.C.K., principal investigator). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Descriptor Number: 16.2.

The authors declare no conflicts of interest.

C.A.K., T.A.G., L.J.W., M.E.R., S.L.V., and J.M.N. participated in research design. C.A.K., T.A.G., L.J.W., C.C.K., R.C.D., and J.M.N. participated in writing of the article. C.A.K., T.A.G., L.J.W., S.L.V., and J.M.N. participated in the performance of the research. L.J.W., M.E.R., S.L.V., and J.M.N. contributed new reagents or analytic tools. C.A.K., T.A.G., L.J.W., S.L.V., C.C.K., and J.M.N. participated in data analysis. Mayo Clinic does not endorse specific products or services included in this article.

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Correspondence: Cesar Keller, MD, Mayo Clinic Transplant Center, 3600 San Pablo Rd, Jacksonville, FL 32224. (

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