A rejoinder on cost-effectiveness of kidney and liver transplantation
Last week, we discussed the cost-effectiveness of kidney transplantation, which has been shown by various scientifically designed economic studies to be well worth the money spent on the surgery for patients with end-stage kidney problems.
On the long term, the surgery actually pays for itself directly and indirectly, so we said there is a 100-percent return on investment (ROI), i.e., the money spent for the operation.
One of our readers, who signed his name as Mamerto, does not seem to agree and he says an ROI “just does not exist” in kidney transplantation since the cost of treatment after the surgery is “almost as high as having thrice-weekly dialysis.” He agrees, though, that dialysis is not a good long-term option for the patient and that with kidney transplantation, “the quality of life of the patient will be vastly better.” He closes his message, saying “kidney transplant is as close as science could get to an outright cure.”
Prevent organ rejection
By “cost after transplant surgery,” Mamerto is most likely referring to the cost of drugs needed to prevent rejection of the transplanted kidney, and there’s no question that the drugs can be expensive. The doses may be relatively high on the first several months after surgery, but once the patient shows no sign of rejection, they are usually tapered to much smaller, maintenance-only amount in subsequent years. So, the cost of necessary drugs after transplant progressively decreases over time.
Researchers use a complicated-but-reliable method to determine if a treatment or surgery is cost-effective or not. Both direct and indirect costs are taken into consideration.
Direct costs would include the cost of drugs and other treatments, laboratory exams, clinic visits or hospitalizations, and all other expenses related to the disease. However, there are also indirect costs, like the decreased productivity or inability to work for a living, hence decreased income, when one has a disabling disease like end-stage kidney disease.
So after a successful kidney transplant, and with the improved quality of life and recovered strength, one can go back to work and earn more money. This and other factors have to be considered in the cost-effectiveness equation. It’s really a complicated research methodology which needs a more lengthy explanation, but suffice it to say that all cost-effectiveness studies on kidney transplant show that it is highly cost-effective compared to continued dialysis, and it should be immediately considered as the treatment of choice when one is diagnosed with end-stage kidney disease.
How about liver transplantation? Is it also as cost-effective as kidney transplantation?
Through the initiatives of the Department of Health, the PhilHealth, the Philippine Charity Sweepstakes Office, and the National Kidney and Transplant Institute, the poor can also avail themselves of the assistance package for the even more expensive liver transplantation surgery. The operation costs anywhere from P1.5 million to P3 million in the Philippines, depending on where it is done.
Survival rates of liver transplant patients have dramatically improved in the last 15 years with better antirejection drugs and supportive care. However, the improvement in the quality of life is not as much after liver transplantation as compared to kidney transplantation. Many patients would still have a relatively low level of occupational functioning months or years after the surgery.
That means the improvement in work productivity to be able to earn some money to subsidize one’s own medical expenses, and the other regular expenses of his or her family is not that much that it can convincingly tilt the balance to the cost-effective side of the equation in the same degree as kidney transplantation does.
Backsliding
There is also a concern for those with end-stage liver disease due to alcoholic cirrhosis. After liver transplant surgery, some of these patients go back to their drinking and they subsequently end up in the same situation they were before—with end-stage liver problem. Everything that was invested in the surgery is therefore wasted.
Another concern is that if the long-term monitoring and maintenance program for these transplant patients is not in place, they can readily develop all sorts of complications such as infection and rejection of the transplanted organ.
I believe there are more than 30 liver transplant cases done in our country since the ’80s. It would be good to review all data on these cases and come up with some cost-effectiveness information in a low-resource setting.
Our proponents of the financial assistance program can analyze the subset of patients who can be classified as marginalized or not so financially well off. How did they fare? How long did they survive after surgery? How was the quality of life before and after liver transplantation? What are their complications, and were these promptly addressed and treated? Were they able to live a normal or near-normal life after the transplantation? Were they able to go back to work?
What may be theoretically ideal may not be practicable yet in our local setting.
Just to put things in perspective, the money invested in one liver transplant case would be sufficient to subsidize the open-heart surgery on 10-12 children and young adults with severe inborn or congenital heart problems or rheumatic heart disease. The surgery is definitely more life-changing and the cost of maintenance drug treatment after surgery is minimal.
We really need to do some math in making decisions on some medical problems. I fully support the objective to make the poor enjoy the benefits modern medicine could offer. But we may have to tweak our programs a little bit to see where we could get the best outcome for every peso spent.
