Lung Transplant Can Avert Significant Health Care Costs for Some Patients, Study Finds

Lung transplantation is an effective, life-saving intervention for patients with advanced lung disease but is associated with a high cost and utilizes scarce resources. As its associated costs continue to rise, questions regarding the procedure's cost-effectiveness exist. New research from Cleveland Clinic has reframed this discussion by exploring costs averted by lung transplant. The study, which appeared in Chest, shows that while end-of-life hospitalization costs varied across patient populations, significant health care costs could be averted for select patients who undergo lung transplantation.

“There have been several studies on the costs associated with lung transplantation, but their methods have been variable, so it is hard to provide clear estimates on costs of the procedure and associated care,” says Carli Lehr, MD, PhD, a staff pulmonologist in Cleveland Clinic’s Respiratory Institute and lead author of the study. “With our study, we wanted to start with the basics and explore which costs could potentially be averted with a lung transplant. It's a hard thing to estimate, but it is an important consideration when looking at cost-effectiveness in the field of transplant.”

Study design

The study included 10 years of data (2009-2019) from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) representing 1,000 hospitals across 37 states. The study included all hospital admissions of patients between 18 to 74 years with pulmonary disease. The authors organized the patients into four disease groups: obstructive lung disease (e.g., chronic obstructive pulmonary disease [COPD]), pulmonary vascular disease (e.g., idiopathic pulmonary arterial hypertension), cystic fibrosis and immunodeficiency disorders, and restrictive lung disease (e.g., idiopathic pulmonary fibrosis [IPF]).

The group used ICD codes to identify pulmonary disease admissions, complications, and procedures and interventions given during hospitalizations. The authors focused primarily on the following procedures: bronchoscopy, tracheostomy, mechanical ventilation, extracorporeal membrane oxygenation (ECMO), transfusion, dialysis and treatment for recorded hospital-acquired infections. The total charges for hospitalizations were calculated and stratified by patient status at time of discharge. The authors also assessed trends in charges over time by demographic and hospital factors.

Findings

The study included 109,024 hospital admissions for pulmonary disease that resulted in in-hospital mortality, which represented 4.1% of all pulmonary admissions. Most of these admissions were for obstructive lung disease (88.7%) followed by 10.6% of patients were admitted for restrictive lung disease, 0.39% for pulmonary vascular disease and 0.31% for cystic fibrosis.

The authors found that compared with hospital admissions resulting in the individual being discharged alive, hospital mortalities tended to occur among patients who were older (65 vs. 62 years), more likely to be male (53% vs. 45.2%), insured by Medicare (62.6% vs. 58.6%), admitted via hospital transfer (12.1% vs. 3.8%), had higher income (14.4% vs. 12.2% in ≥ 76th percentile) and a longer median length of stay (4.8 vs. 3.5 days).

Patients who died during hospitalization also tended to undergo more procedures and interventions (52.3% vs 8.2% had two or more interventions) and experienced more hospital-acquired infections (5% vs 1.4%).

Admission and hospital traits differed by pulmonary diagnosis. The median age across diagnoses was 65.4 years for obstructive lung disease, 59.2 years for pulmonary vascular disease, 28.9 years for cystic fibrosis and 65.8 years for restrictive lung disease. Admissions were higher for non-Hispanic Black patients with pulmonary vascular disease (23.1%) compared with other diagnosis groups (7.3% - 12.1%). Of the disease groups, individuals with cystic fibrosis had the most interventions, and mechanical ventilation was the most common intervention (76.4% vs. 58%-69.6%). Tracheostomies were the second most common procedure, and they were performed more often with cystic fibrosis admissions.

“After looking at admission rates and procedures, we studied those who died in the hospital to estimate the costs incurred that would be avoided if that person had undergone a lung transplant”, says Dr. Lehr.

Dr. Lehr explains that the inpatient costs from HCUP were converted from total charges for each hospital discharge, and those charges represent the amount the hospitals billed for services. However, she notes that “charges” are different from “costs,” which are the actual expenses incurred in the production of hospital services. HCUP provides hospital-specific cost-to-charge ratios based on all-payer inpatient cost for nearly every hospital in the NIS. These ratios allow the conversion of the HCUP charges into cost estimates.

“We found that an end-of-life hospitalization had an average cost of $29,000,” says Dr. Lehr. “But there are variable costs among in-hospital mortality admissions depending on diagnosis — we found a range of $28,494 for admissions due to obstructive lung disease to $82,178 for admissions due to cystic fibrosis. We also found that the variance wasn’t due to longer hospital stays, but rather it was driven more by increased use of interventions, such as mechanical ventilation or dialysis. Costs were also higher for younger patients, though this was likely driven by the fact that they typically had more procedures.

Takeaways

The authors note that while U.S. healthcare spending is already at an all-time high, an aging population and medical technology advancements will likely result in continued cost increases. Furthermore, the costs for patients with advanced lung disease typically escalate as the disease progresses leading to compounding costs and more hospital admissions.

When separating hospital admissions for patients by disease, the group found that admissions for people with obstructive lung disease, such as COPD, accounted for 94.1% of hospitalizations and 88.1% of cases of in-hospital mortality. On the other hand, admissions for patients with restrictive lung disease, like IPF, accounted for only 4.7% of hospitalizations but 10.6% of in-hospital mortality. Although admissions for restrictive lung disease were not significantly increasing, their associated costs were higher than care for patients with obstructive lung disease.

“Hospitalization costs do not account for all of the other costs that we know are associated with care — such as medication costs,” Dr. Lehr explains. “We know that patients with IPF use antifibrotic medications that cost them hundreds of thousands of dollars over the course of a year, and those costs are important to consider and are often incurred directly by patients.”

She continues, “Lung transplant is a valuable intervention and one that if used in the right population, gives people a second chance at life in the way that no medicine we have yet discovered for any of these diseases can. For patients with IPF or COPD, transplant is something that we can offer them when they have exhausted medical options. The demand for lung transplant still far exceeds the supply, but having a better understanding of the costs associated with end-of-life hospitalizations for people with pulmonary disease will be essential for future studies that evaluate the cost-effectiveness of lung transplantation.”