title: Impact of the lung allocation score on survival beyond 1 year.
abstract: Implementation of the lung allocation score (LAS) in 2005 led to transplantation of older and sicker patients without altering 1-year survival. However, long-term survival has not been assessed and emphasizing the 1-year survival metric may actually sustain 1-year survival while not reflecting worsening longer-term survival. Therefore, we assessed overall and conditional 1-year survival; and the effect of crossing the 1-year threshold on hazard of death in three temporal cohorts: historical (1995-2000), pre-LAS (2001-2005) and post-LAS (2005-2010). One-year survival post-LAS remained similar to pre-LAS (83.1% vs. 82.1%) and better than historical controls (75%). Overall survival in the pre- and post-LAS cohorts was also similar. However, long-term survival among patients surviving beyond 1 year was worse than pre-LAS and similar to historical controls. Also, the hazard of death increased significantly in months 13 (1.44, 95% CI 1.10-1.87) and 14 (1.43, 95% CI 1.09-1.87) post-LAS but not in the other cohorts. While implementation of the LAS has not reduced overall survival, decreased survival among patients surviving beyond 1 year in the post-LAS cohort and the increased mortality occurring immediately after 1 year suggest a potential negative long-term effect of the LAS and an unintended consequence of increased emphasis on the 1-year survival metric.
authors.affiliation: Department of Anesthesiology and Medicine, Stanford University School of Medicine, Stanford, CA.
authors.forename: B G
authors.initials: BG
authors.lastname: Maxwell
authors.forename: J E
authors.initials: JE
authors.lastname: Levitt
authors.forename: B A
authors.initials: BA
authors.lastname: Goldstein
authors.forename: J J
authors.initials: JJ
authors.lastname: Mooney
authors.forename: M R
authors.initials: MR
authors.lastname: Nicolls
authors.forename: M
authors.initials: M
authors.lastname: Zamora
authors.forename: V
authors.initials: V
authors.lastname: Valentine
authors.forename: D
authors.initials: D
authors.lastname: Weill
authors.forename: G S
authors.initials: GS
authors.lastname: Dhillon
mesh_terms: D015331:Cohort Studies; D015276:Health Care Rationing; D006801:Humans; D016040:Lung Transplantation; D015996:Survival Rate
keywords: Clinical research/practice; Scientific Registry for Transplant Recipients (SRTR); ethics; health services and outcomes research; lung transplantation/pulmonology; organ allocation; organ transplantation in general; patient survival; risk assessment/risk stratification; social sciences