PITTSBURGH, March 1, 1999 — Intestinal transplantation should no longer be called "experimental," say authors from the University of Pittsburgh Medical Center (UPMC) in the February/March issue of the journal Transplantation Proceedings, citing improved survival rates that match those for organs currently approved for reimbursement by the U. S. Health Care Financing Administration (HCFA) as well as data proving its cost-effectiveness.
University of Pittsburgh surgeons report a 72 percent one-year patient survival rate in their review of 115 transplants performed between 1990 and 1998 in 109 patients with irreversible intestinal failure. Such results are comparable to lung transplantation, which HCFA recognizes as a reimbursable procedure under its Medicare program, say the authors.
"Therefore, it is justifiable to consider intestinal transplantation as a nonexperimental procedure that is eligible for reimbursement," writes lead author Kareem Abu-Elmagd, M.D., Ph.D., FACS, associate professor of surgery and director of intestinal transplantation at the University of Pittsburgh’s Thomas E. Starzl Transplantation Institute .
According to the United Network for Organ Sharing, lung transplants have a one-year patient survival rate of 70.4 percent. State Medicaid and other third-party payers usually follow Medicare reimbursement guidelines.
Surgeons report that improved management of rejection, refined donor and recipient selection criteria and modification of the surgical procedure, including donor bone marrow augmentation, have contributed to the current one-year results. In addition, these modifications have significantly improved survival for patients transplanted in the last four years, for whom there is a cumulative 65 percent survival rate. For children, five-year survival is 68 percent. There are currently 55 patients alive, 31 of whom are able to maintain good nutrition more than three years following their transplant and 18 who are beyond the five-year milestone.
The small intestine can be transplanted in one of three ways: alone; in combination with the liver; or in combination with the liver, pancreas and stomach. The majority (81 percent) of the patients at the UPMC required intestinal transplants because of short-gut syndrome, the loss of more than 70 percent of the intestine due to trauma, surgery or disease. For adults, short-gut syndrome may be caused by trauma or Crohn’s disease; for children, it may be a volvulus—a twisting of the intestines, or congenital conditions.
Patients with intestinal failure must be sustained nutritionally with intravenous feedings called total parenteral nutrition (TPN). Liver failure often results after long-term use, hence the need for a life-saving combined liver and intestine transplant in some patients. But as a preventive measure against the likelihood of liver failure and to improve the quality of life for patients who still have the option of TPN, a transplant of the small intestine is a more cost-effective alternative, say the authors.
According to 1992 Medicare figures cited in the article, TPN’s annual price tag is $150,000, a conservative figure that does not include associated costs for medical equipment, nursing home-health care and frequent hospitalizations. Today’s costs are believed to be much higher.
"Based on these data, intestinal transplantation becomes cost-effective by the second year after transplantation," report the authors, who also note the costs to perform the three types of transplants at their center have markedly declined.
"Transplanting the small intestine alone, before complications arise, is clearly cost-effective therapy for patients who still have the option of TPN," says Dr. Abu-Elmagd.
"Fifty-one (93 percent) of our 55 current survivors are completely off TPN with full nutritional autonomy and improved quality of life. These are results that Medicare ought to pay attention to," argues Dr. Abu-Elmagd who, with other UPMC surgeons, has written to HCFA to ask that intestinal transplants be covered at centers with the most experience.
The UPMC has performed about 40 percent of all the intestinal transplants performed worldwide and reported to the International Intestinal Transplant Registry.