Introduction: Economic analysis of liver transplant (LT) practice has generally focused on the LT episode and post-LT care. Consequently, the economic impact of the geographic variation in severity of illness on the LT waiting list has not been described.

Methods: A novel dataset linking Medicare claims with transplant (OPTN) registry data was used to assess pre-transplant cost for patients (N=15,710) with end stage liver disease (ESLD). Using MELD updates collected by the OPTN, the cost per waiting-list-month was analyzed using multivariate linear regression models to adjust for additional recipient characteristics both nationally and for each OPTN region. MELD was analyzed using splines to allow for non-linear patterns.

Results: Claims data for 249,434 waitlisted patient-months on the were included. Patient characteristics associated with increased waiting list costs included older age, female gender, hepatocellular carcinoma, diabetes, hypertension, and continuously updated MELD score (P<.05 for all). African American race, Hispanic ethnicity, and private insurance were all associated with reduced monthly costs.

Higher MELD dramatically increased waitlist costs (p<.0001). (Figure) Thus, for an average recipient, the expected monthly cost of care for a patient with a MELD of 20 ($2030) was approximately 10% of the monthly cost of care at a MELD of 30 ($22,685). The cost implications of MELD varied by OPTN region. The monthly cost of a MELD 30 patient varied from $19,548 (Region 10) to $36,099 (Region 7)(Table)

Conclusion: Increasing severity of illness resulted in dramatically higher costs for waiting list patients. Reducing the number of high MELD patients may reduce total spending for end stage liver care. Regional variation in waitlist costs may reflect the impact of longer waiting times at high MELD scores in certain areas.

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