Preliminary results of a liver allocation plan using a continuous medical severity score that de-emphasizes waiting time.
Liver allocation remains problematic because current policy prioritizes status 2B or 3 patients by waiting time rather than medical urgency. On February 21, 2000, we implemented a variance to the United Network for Organ Sharing liver allocation policy that redefined status 2A by much more rigid, definable criteria and prioritized status 2B patients by using a continuous medical urgency score based on the Child-Turcotte-Pugh score and other medical conditions. In this system, waiting time is used only to differentiate status 2B candidates with equal medical urgency scores. Comparing the 6-month period (period 1; n = 67) before implementation of this system to the 6-month period after implementation (period 2; n = 75), there was a significant reduction in the number of transplantations performed for patients listed as status 2A (46.3% to 14.7%; P =.002) and an increase in the number of patients listed as status 2B who received transplants (44.8% to 70.7%; P =.10). Most dramatically, there was a 37.1% reduction in overall deaths on the waiting list from 94 deaths in period 1 to 62 deaths in period 2 (P =.005), with the most significant reduction for patients removed from this list at status 2B (52 v 18 patients; P =.04). There were 3 postoperative deaths in each period, with only 1 graft lost in period 2. Status 2B patients with the greatest degree of medical urgency received transplants without multiple peer reviews requesting elevation to 2A status. We conclude that a continuous medical urgency score system allocates donor livers much more fairly to those in medical need and reduces waiting list mortality without sacrificing efficacy.
New England Medical Center/Tufts University School of Medicine, Division of Transplant Surgery, Box 40, 750 Washington St., Boston, MA 02111, USA. rfreeman@lifespan.org
R B
RB
Freeman
R J
RJ
Rohrer
E
E
Katz
W D
WD
Lewis
R
R
Jenkins
A B
AB
Cosimi
F
F
Delmonico
A
A
Friedman
M
M
Lorber
K
K
O'Connor
J
J
Bradley
D015276:Health Care Rationing / Q000379:methods*; D006801:Humans; D016031:Liver Transplantation / Q000706:statistics & numerical data*; D009511:New England; D018579:Patient Selection; D012720:Severity of Illness Index; D013997:Time Factors; D009927:Tissue and Organ Procurement / Q000379:methods* / Q000706:statistics & numerical data; D014850:Waiting Lists