SURGERY 217 T HE BURGEONING INFLUENCE of managed care in transplantation, especially orthotopic liver trans- plantation (OLTx), coupled with a shrinking health care dollar has placed most transplant pro- grams under intense pressure to lower costs while at the same time sustaining quality of care. The optimal cost-effective patient care protocol after OLTx has yet to be defined and awaits a better understanding of the relationship between clinical variables and resource utilization. Published reports focusing on resource utilization after liver transplantation are few and have often used charge data as a proxy for costs and resource uti- lization. This is problematic because charges reflect many parameters besides costs, 1 may vary considerably from region to region, hospital to hospital, or even within hospitals, 2,3 and can gen- erally introduce considerable error into the calcu- lation. Activity-based cost accounting systems have been shown to provide a more accurate assessment of resource utilization. 3-5 Patient survival after liver transplantation is inversely related to the patient’s condition before transplant. 6 It follows that morbidities after trans- plantation, and thereby total costs, might also be related to the pretransplant physiologic condition. Kim et al 7 identified several physiologic pretrans- The influence of clinical variables on hospital costs after orthotopic liver transplantation James F. Whiting, MD, Jill Martin, PharmD, Edward Zavala, MBA, and Douglas Hanto, MD, PhD, Cincinnati, Ohio Background. The burgeoning influence of managed care in transplantation, coupled with a shrinking health-care dollar, has placed most transplant programs under intense pressure to cut costs. We under- took a retrospective cost-identification analysis to determine what clinical variables influenced financial outcomes after orthotopic cadaver liver transplants (OLTx). Methods. Fifty patients receiving 53 transplants between April 1995 and November 1996 were reviewed. Clinical data were obtained from our institution’s transplant database, and total costs (not charges) for the transplant admission and the 6 months after transplant were obtained with use of an activity-based cost accounting system (HBOC Trendstar, Atlanta, Ga). Results. The average total cost of second transplants (n = 5) was $97,262 greater than for first trans- plants (n = 48, P < .05). Patients transplanted initially as United Network for Organ Sharing (UNOS) status 2 (n = 20) incurred average costs that were $51,762 higher than for patients transplanted as UNOS status 3 (n = 28, P = .008). Patients with a major bacterial or fungal infection (n = 28) incurred average costs $46,282 higher than recipients who were infection free (n = 22, P = .02). Multivariate analysis demonstrated that only length of stay, retransplantation, and postoperative dialy- sis were significantly and independently correlated with costs (r 2 = .605). When the model was repeated with preoperative variables alone, only UNOS status was significantly correlated with 6-month total costs (P = .006, r 2 = .16). Conclusions. Length of stay is the most important determinant of costs after OLTx. Rational strategies to design cost-effective protocols after OLTx will require further studies to truly define the cost of various morbidities and outcomes after OLTx. (Surgery 1999;125:217-22.) From the Departments of Surgery and Pharmacy and Administration, University of Cincinnati Medical Center Accepted for publication Aug 10, 1998. Reprint requests: James F. Whiting, MD, University of Cincinnati Department of Surgery, 231 Bethesda Ave, PO Box 67055, Cincinnati, OH 45267-0558. Copyright © 1999 by Mosby, Inc. 0039-6060/ 99/ $8.00 + 0 11/ 60/ 93791 Surgical outcomes research