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Does the Primary Indication for Lung Transplantation Impact Resource Utilization?
*Andrew Kalra1,2, *Jessica Ruck1, Amy Feng1, Winnie Liu1, Alice Zhou1, Armaan Akbar1, Alfred Casillan1, Sean Agbor-Enoh1, Christian Merlo1, *Errol Bush1
1The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States, 2Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
Objective: Lung transplantation (LT) is a life-saving procedure associated with substantial expenses. There is limited data on inpatient resource utilization for LT recipients categorized by primary indication, which is important given their different pathophysiology and overall management.
Methods: We studied adult LT recipients in the National Inpatient Sample that were classified by one of four primary pulmonary diagnoses: obstructive (COPD), restrictive (IPF), cystic fibrosis (CF), and pulmonary vascular (IPAH). We compared characteristics of LT recipients in each group (2005-2020). We compared the length of hospital stay, inflation-adjusted total hospitalization costs, and discharge disposition between groups. Multivariable generalized linear regression was used to determine if length of hospital stay was associated with pulmonary diagnosis group, adjusting for recipient age, sex, race, Charlson Comorbidity Index (CCI); single/bilateral LT; and ex-vivo lung perfusion, ECMO, mechanical ventilation, tracheostomy, bronchoscopy, transfusion, and dialysis.
Results: Of 27,422 LT recipients, 15,801 (57%) were IPF, 7,604 (28%) were COPD, 2,916 (11%) were CF, and 1,101 (4%) were IPAH. The proportion of recipients in each primary pulmonary diagnosis group in NIS was comparable to data reported in UNOS in the study period (Figure 1). Recipients with CF (median age=32 years) and IPAH (50 years) were younger than COPD (60 years) and IPF (62 years, p<0.001) recipients. Sex, race, CCI, recipient hospitalization region, primary insurance type, and median household income significantly differed between all 4 groups (all p<0.05).
Unadjusted length of hospital stay overall was longest for IPAH recipients (22 days, IQR=12-53), followed by CF (20 days, 14-34), IPF (18 days, 12-35), and shortest for COPD (16 days, 11-25, p<0.001, Table). Trend analysis of length of hospital stay demonstrated that there were significant fluctuations in length of stay between each group, with length of stay peaking at 38 days for both CF (2020) and IPAH (2017) recipients (Figure 2A). After adjustment, compared to IPF recipients, IPAH recipients had a longer length of stay (8.43 days, 95%CI=1.75-15.11, p=0.01), while COPD recipients had a shorter length of stay (-1.77 days, 95%CI=-3.50 to -0.04, p=0.044). Unadjusted inpatient costs were highest for IPF recipients ($157,228, $113,127-$246,215), followed by IPAH ($151,999, $111,725-$250,715), CF ($149,402, $105,379-$235,381), and lowest for COPD ($138,116, $105,244-201,091, p<0.001, Table). Trend analysis of inpatient hospitalization costs demonstrated significant cost fluctuations between each group, with costs peaking at $361,430 for IPAH recipients (2016) (Figure 2B).
Most COPD recipients were discharged routinely from the hospital (n=3,920, 52%). IPF recipients had the highest proportion of recipients discharged to care facilities (n=3,028, 19%), while CF recipients had the highest proportion discharged to home health care (n=1,158, 40%, p<0.001). IPAH recipients were more likely to die than recipients in other pulmonary diagnosis groups (n=116, 11%).
In a subgroup analysis of recipients with concomitant cardiac surgery (n=200), the median length of hospital stay was similar between concomitant cardiac surgery recipients and non-concomitant cardiac surgery recipients (22 days, 95%CI=14-47 vs. 18 days, 95%CI=12-33, p=0.36). Median hospitalization costs were also similar between concomitant cardiac surgery recipients and non-concomitant cardiac surgery recipients ($167,308, 95%CI=$125,386-$290,801 vs. $150,511, 95%CI=$109,568-$230,778, p=0.41).
Conclusions: While IPAH and CF LT recipients may remain in the hospital longest post-transplant, IPF recipients incur the highest inpatient hospitalization costs. COPD recipients may experience the least financial burden of LT recipients. Indication for LT may be an essential marker for resource utilization overall.
Table. Comparison of resource utilization and outcomes between each pulmonary diagnosis group for lung transplant recipients.
Figure 1. Trends of pulmonary diagnosis group over time in A) HCUP NIS 2005-2020 (this study) and B) UNOS (2005-2020).
Figure 3. Trend analysis of A) length of hospital stay and B) inpatient hospitalization costs between each pulmonary diagnosis group over time (2005-2020) in HCUP NIS.
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