title: Clinician assessments of health status predict mortality in patients with end-stage liver disease awaiting liver transplantation.
abstract: OBJECTIVE
  The US liver allocation system effectively prioritizes most liver transplant candidates by disease severity as assessed by the Model for End-Stage Liver Disease (MELD) score. Yet, one in five dies on the wait-list. We aimed to determine whether clinician assessments of health status could identify this subgroup of patients at higher risk for wait-list mortality.
  
  
  METHODS
  From 2012-2013, clinicians of all adult liver transplant candidates with laboratory MELD≥12 were asked at the clinic visit: 'How would you rate your patient's overall health today (0 = excellent, 5 = very poor)?' The odds of death/delisting for being too sick for the transplant by clinician-assessment score ≥3 vs. <3 were assessed by logistic regression.
  
  
  RESULTS
  Three hundred and forty-seven liver transplant candidates (36% female) had a mean follow-up of 13 months. Men differed from women by disease aetiology (<0.01) but were similar in age and markers of liver disease severity (P > 0.05). Mean clinician assessment differed between men and women (2.3 vs. 2.6; P = 0.02). The association between clinician-assessment and MELD was ρ = 0.28 (P < 0.01). 53/347 (15%) died/were delisted. In univariable analysis, a clinician-assessment score ≥ 3 was associated with increased odds of death/delisting (2.57; 95% CI 1.42-4.66). After adjustment for MELD and age, a clinician-assessment score ≥ 3 was associated with 2.25 (95% CI 1.22-4.15) times the odds of death/delisting compared to a clinician-assessment score < 3.
  
  
  CONCLUSIONS
  A standardized clinician assessment of health status can identify liver transplant candidates at high risk for wait-list mortality independent of MELD score. Objectifying this 'eyeball test' may inform interventions targeted at this vulnerable subgroup to optimize wait-list outcomes.
authors: Department of Medicine, University of California, San Francisco, CA, USA.
authors: Jennifer C
authors: JC
authors: Lai
authors: Department of Medicine, University of California, San Francisco, CA, USA.
authors: Kenneth E
authors: KE
authors: Covinsky
authors: Department of Medicine, University of California, San Francisco, CA, USA.
authors: Hilary
authors: H
authors: Hayssen
authors: Department of Medicine, St. Elizabeth's Medical Center, Boston, MA, USA.
authors: Blanca
authors: B
authors: Lizaola
authors: Department of Medicine, University of California, San Francisco, CA, USA.
authors: Jennifer L
authors: JL
authors: Dodge
authors: Department of Medicine, St. Elizabeth's Medical Center, Boston, MA, USA.
authors: John P
authors: JP
authors: Roberts
authors: Department of Medicine, University of California, San Francisco, CA, USA.
authors: Norah A
authors: NA
authors: Terrault
authors: Department of Surgery, University of California, San Francisco, CA, USA.
authors: Sandy
authors: S
authors: Feng
mesh_terms: D000368:Aged; D058625:End Stage Liver Disease / Q000401:mortality* / Q000601:surgery*; D005260:Female; D006304:Health Status; D006801:Humans; D016031:Liver Transplantation; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011379:Prognosis; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D014850:Waiting Lists
keywords: clinical judgment; health status; wait-list mortality
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