Heteroestructralista

As noted in 3.2.4 above there were no health economic studies found that pertained to the duration of abstinence.

Longworth 2003106 _{reported incremental cost-effectiveness ratios for liver transplant} of £48,000 per QALY gained for ALD patients, £29,000 per QALY gained for PBC patients, and £21,000 per QALY gained for PSC patients. The study considered the initial assessment cost and the time on the waiting list, this being integral components of the UK liver transplantation program. The cost for pre-transplant assessment influenced largely the result for ALD patients: “The larger incremental cost-per-QALY ratio for ALD patients is in part the influence of a larger proportion of ALD patients being considered unsuitable for transplantation after undergoing the assessment process. A reduction in the size of this group of patients, possibly through better evaluation of patients before assessment at transplant centres, would reduce the mean incremental cost-per-QALY ratio for the ALD group”106_{. In addition, the author}

mention that if calculated from the time of transplantation (i.e. excluding assessment costs), the incremental cost-effectiveness ratio would be over 50% lower.

This study showed that referring ALD patients for liver transplantation under the 1995-1996 system was not cost-effective and that better referral criteria in primary

130 and secondary care would improve the cost-effectiveness ratio. Hence, the specifics of the referral process for liver transplant for ALD patients might have significant impact on service costs.

An important limitation of the study is that it measured cost-effectiveness of liver transplantation only up to 27 months from time of listing. A lifetime analysis is more appropriate as mortality is impacted by the intervention. In addition, a longer time frame may better cover all costs and benefits related to the intervention, and is likely to increase the QALY gain and improve the cost-effectiveness ratio in favour of transplantation. Furthermore, clinical and resource use data were collected from a 1995-1996 prospective cohort. Discussions with clinical experts suggest that the current UK referral pathway is now much more selective and presumably more cost- effective than it was at the time of the study.

This study has significant limitations. The GDG felt that liver transplantation in its current form is likely to be cost-effective for ALD patients, when long-term benefits and modern selection practices are taken into account.

3.2.6 F

Only one small case series was reviewed105 _{and limited results of interest were} reported.

It was found that improvement in liver function, if it occurred at all following abstinence from alcohol, was always evident within three months. This is in agreement with the clinical experience of GDG members.

The paper reported on abstinent (those who declared they were abstinent and

confirmed by biological markers), sober (those who decreased their consumption to a non-excessive level: less than 3 units per day for a man, 2 units for a woman; with normalisation of GGT and MCV) and relapsing (one or more periods of abstinence alternating with periods of excessive consumption) people. The GDG agreed that while the study findings were not in completely abstinent people, it was important to

include the term ‘abstinent’ be included in the recommendation, particularly as it concerns the allocation of a public resource.

The GDG recognized that there are patients, particularly with alcohol-related hepatitis, that will not survive the three months until they are referred. Currently, alcohol- related hepatitis is a contra-indication to liver transplantation in the UK, and our recommendations are in keeping with the national recommendations for the

indications for transplantation. The GDG understand that this may change in the future and this recommendation may need reviewed and adapted should the national

recommendations change.

The health economic analysis by Longworth et al. conducted from a UK perspective concluded that liver transplantation was not cost-effective for alcohol liver disease patients, mainly because of the lack of selectivity of the 1995-1996 referral scheme,

131 leading to important additional cost in assessing unsuitable patients for

transplantation. The GDG agreed that optimising the selection of patients before assessment at transplant centres is essential, and noted that while the referral process may have led to a reduction in the number of people being inappropriately referred since 1995, there is still room for improvement. In addition, when a referred patient is seen at a transplant centre, there is a tendency to repeat many of the costly tests that have already been carried out, and an improvement in communication between the transplant centres and the referring hospitals may effect substantial cost savings.

3.2.7 R

R26 Refer patients with decompensated liver disease to be considered for assessment for liver transplantation if they:

still have decompensated liver disease after best management and 3 months’ abstinence from alcohol and

are otherwise suitable candidates for liver transplantationm_.

m _{For the nationally agreed guidelines for liver transplant assessment in the context of alcohol-related}

liver disease, see

www.uktransplant.org.uk/ukt/about_transplants/organ_allocation/pdf/liver_advisory_group_alcohol_gui delines-november_2005.pdf

132

3.3 C

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