Effects of organ supply and demand on economic decision-making, cost, access and outcomes of liver transplantation

Liver transplantation (LT) provides benefit of reduced mortality and increased quality of life. Increasing demand for organs, current allocation policies and variation in organ supply and demand across geography create challenges for optimizing benefit of LT to patients, transplant centers and society.;This dissertation aims to quantify the economic burden of high-risk donor and recipient practices for LT centers using large, cost and clinical data. This dissertation also focuses on associations between high-risk transplants, costs, patient care decisions, and disparities based on socioeconomic status (SES) and ability to relocate to better supplied regions to improve access and outcomes of LT.;The first aim answers the questions: are costs of LT admission and one-year post-transplant readmissions associated with patient and donor characteristics? Does cost associated with donor quality vary across severity of recipient illness? The study found that donor quality and recipient severity of illness synergistically increase the cost of LT. Among the donor characteristics, donation after cardiac death, older donors, minority donors, nationally shared organs, and cold ischemic times 7--13 hours had the greatest impact on transplant costs. The second aim answers the questions: Do relocation to different Donor Service Area (DSA) and SES impact access, waitlist mortality, cost and outcomes of LT? Does quality of livers vary across SES groups and for individuals who relocated for their transplant? This study found that high SES was associated with increased access to LT and reduced mortality. Increased access was mediated through travel. Travel was associated with high SES, white race, blood group O, listing region, and private insurance. Transplant candidates with highest SES were more likely to move. Inter-DSA travel was associated with reduction in LT costs and receipt of higher risk organ. The findings also validate the assumption that travelers target the centers with better organ supply.;The findings of this dissertation indicate need for improved organ allocation policies that balance cost of care, organ supply and burden of severity of illness across geography as well as decrease waiting list and post-transplant mortality and reduce healthcare spending.