title: A commercial transplant network's perspective of value in solid organ transplantation: Strategizing for value in transplant care.
abstract: BACKGROUND
  Solid organ transplantation has been an area of great interest to commercial payers ever since it moved into mainstream medical care beginning in the 1980s. Over the years a system of evaluating transplant program performance based on volume and one year graft and patient survival has developed. While this system has served its purpose, there is an increasing realization from payers that a need exists for a more sophisticated way to evaluate quality and cost-effectiveness of these complex procedures. We report on the perspective of a large transplant network and its efforts to better understand the drivers of value over the entire continuum of care from referral through one year post-transplant.
  
  
  METHODS
  We evaluated members of a large commercial health plan who were referred for solid organ transplantation between January 1, 2010 and April 30, 2014. A total of 18,453 cases were evaluated for both clinical and economic outcomes.
  
  
  RESULTS
  We report on two areas that can impact value over the entire continuum of care. Large variation in clinical practice and cost was noted. The observed variation was independent of inclusion in the transplant network's preferred network. The average pre-transplant and post-transplant costs for kidney, liver and heart transplantation cases at center level showed a variation of between 18 and 250% of the network's average. Clinical outcomes of median days on the waitlist, waitlist mortality and readmission within thirty days after transplant also showed wide variation. There was similar wide variation in cardiac evaluation of transplant candidates despite the existence of published recommendations. We demonstrated that pre-emptive renal transplantation is a high value strategy for this membership independent of donor source.
  
  
  CONCLUSIONS
  In the studied population the data show wide variation in both clinical and economic parameters related to the transplant process in programs with statistically similar one year patient and graft survival. These results require further examination. In this era of increased concern about delivering value in medical care we may need to reassess how we evaluate organ transplantation programs.
authors: Complex Medical Conditions, Optum, UnitedHealth Group, 11000 Optum Circle, MN101-W800, Eden Prairie, MN 55344, USA. Electronic address: frank.irwin@optum.com.
authors: Frank D
authors: FD
authors: Irwin
authors: Complex Medical Conditions, Optum, UnitedHealth Group, 11000 Optum Circle, MN101-W800, Eden Prairie, MN 55344, USA. Electronic address: charlotte.wu@optum.com.
authors: Charlotte
authors: C
authors: Wu
authors: Complex Medical Conditions, Optum, UnitedHealth Group, 11000 Optum Circle, MN101-W800, Eden Prairie, MN 55344, USA. Electronic address: wade.bannister@optum.com.
authors: Wade M
authors: WM
authors: Bannister
authors: Complex Medical Conditions, Optum, UnitedHealth Group, 11000 Optum Circle, MN101-W800, Eden Prairie, MN 55344, USA. Electronic address: anthony.bonagura@optum.com.
authors: Anthony F
authors: AF
authors: Bonagura
authors: Complex Medical Conditions, Optum, UnitedHealth Group, 11000 Optum Circle, MN101-W800, Eden Prairie, MN 55344, USA. Electronic address: bart.laihinen@optum.com.
authors: Bart
authors: B
authors: Laihinen
authors: Solid Organ Transplant Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03745, USA. Electronic address: david.a.axelrod@hitchcock.org.
authors: David A
authors: DA
authors: Axelrod
authors: Department of Surgery, Division of Abdominal Transplantation, Saint Louis University, 3660 Vista Avenue, St. Louis, MO 63110, USA. Electronic address: schnitm@slu.edu.
authors: Mark A
authors: MA
authors: Schnitzler
mesh_terms: D003362:Cost-Benefit Analysis; D017408:Guidelines as Topic; D006801:Humans; D016377:Organ Transplantation / Q000191:economics*; D014019:Tissue Donors; D014850:Waiting Lists