A systematic review of the cost-effectiveness of liver transplantation

Background. The efficacy of liver transplantation (LT) in treating liver disease has been established through prospective and retrospective observational studies. Although LT is now regarded as the treatment of choice for liver disease, the evidence on its cost-effectiveness is lacking. Methods. In this study we conducted a systematic review of the studies that have attempted to assess the cost-effectiveness of LT. The aim is not only to assess the value for money of this particular intervention but also to investigate the sources of evidence on probabilities, costs and quality of life values used in the economic evaluations. Results. 6 studies were included in the systematic review, of which 5 were of moderate to high quality. The systematic review identified three separate questions: 1) Cost-effectiveness of LT vs no intervention; 2) LT vs alternative treatments for hepatocellular carcinoma (HCC) and 3) type of LT, specifically donation after brain death (DBD) against donation after cardiac death (DCD). Given that randomized control trials of LT versus no transplantation are neither practical nor ethical, we find the two most common methods of investigation are decision analytic models and observational studies (prospective and retrospective). In the case of models, values for probabilities, costs and utilities are mainly derived from the literature (or expert opinion). In observational studies, instead a hypothetical comparison group is created and values for this group estimated either from prognostic models or from the patients in the waiting list for transplantation. In both cases, sources of uncertainty are multiple because of the use of many assumptions. Conclusions. The evidence reviewed suggests that LT is cost-effective when compared to no transplantation; whilst evidence on LT vs alternative treatment for HCC is inconclusive and evidence on type of LT is dependent on the data which parametrize the model.