Quality assurance, efficacy indicators and cost-utility of the liver pre-transplant patient evaluation algorithm

Background: efficacy of pre-transplant algorithms is crucial to improve standards of care and optimize resource allocation. Aim of the study is to report on a retrospective review of the pre-LT algorithm adopted at our center, illustrate the efficacy indicators and highlight strategies to improve cost-utility. Materials and methods: a retrospective review of the pre-LT evaluation algorithm used at our center. Pre-LT eligibility evaluation is performed on an outpatient basis at a cost per patient (CPP) of 2770 Euros. Objective measures were: overall and per-procedure patients inflow and outflow; referral efficacy rate (RER), as the ratio of patients admitted to pre-LT evaluation to the total of referred patients; evaluation efficacy rate (EER), as the ratio of patients waitlisted for LT to patients admitted to pre-LT evaluation; process efficacy rate (PER), as the ratio of patients waitlisted for LT to the total of referred patients, and the cost per waitlisted patient (CPWP), as CPP/EER. Results: from January 1996 to October 2004, 1837 patients were referred on an outpatient basis for evaluation for LT. Based on evaluation of transmitted clinical data, 412 patients (22.4%) were excluded, while 1425 (77.6%) were admitted to preliminary outpatient clinic consultation. After consultation, 603 patients (42.3%) were excluded from pre-LT eligibility evaluation, in 356 (59%) because of comorbidities contraindicating LT and in 247 (41%) because of early referral. 822 patients (57.7%) were admitted to LT eligibility evaluation and RER was 47.7% (822/1837). Out of the 822 patients evaluated, 338 (41.1%) were excluded from LT waitlisting, in 244 cases (72.2%) because of comorbidities, while in 94 (27.8%) because of early referral, with a cost-utility and EER of 58.8% each (484/822). Thus, of the 1837 patients who were originally addressed for LT eligibility evaluation, 484 were waitlisted, yielding a PER of 26.3% (484/1837) and a CPWP of 4710.8 Euros. Conclusions: the PER of the pre-LT algorithm is low. However, use of RER, EER, and PER allows to monitor the efficacy of the whole process. Strategies to increase PER are reduction of futile referrals; diffusion of eligibility criteria among physicians, and pre-emptive patient charts evaluation. Such a policy might reduce referrals by 42.3% to 60.3%, increase PER to 66.5% and reduce CPWP to 4165.4 Euros.