Center variation in the use of non-standardized MELD exception points
David S. Goldberg1,2, George A. Makar1,Benjamin French2;
1Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia,FA; 2Clinical Center for Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
The MELD score is an imperfect prognosticator of waitlist dropout, thus transplant centers may apply for exception points. Exception applications are categorized as recognized exceptional diagnoses (REDs; e. g. HGG) and non-REDs (e. g. recurrent cholangitis). While prior work has demonstrated regional variation in the use of exceptions, no work has examined the between-center variability in the use, and subsequent approval, of non-RED exceptions. We analyzed all new waitlist candidates from 2/27/02-6/3/11, to explore variation in the use of non-REDs, for which no strict exception criteria exist. Of 58, 641 new waitlist candidates, 4, 356 (7. 4%) applied for a non-RED exception. The number of applications increased over time, as did the approval rates for such applications—nearly 50% in 2002 to 75% in 2010.Adjusting for patient factors, there was significant variability (P<0.001) in the use of non-RED exceptions in 7/11 UNOS regions, and in the approval of these exceptions in 6/11しNOS regions. In 3 しNOS regions, the absolute difference in the adjusted proportion of approved non-RED exceptions between centers with the highest and lowest approval rates was >30%. Variability in the use and approval of non-REDs was clinically significant—waitlist candidates with approved exceptions were significantly more likely to be transplanted (68. 3% vs. 53. 4%, P<0.001) and less likely to be removed for death or clinical deterioration (10.4% vs. 16. 2%, P<0.001). While increased median MELD at transplantation within a donor service area was associated with increased odds of applying for exceptions, no other center factors were associated with applying for, or having non-RED exceptions approved.
Figure 1: Within-region variability in waitlist candidates applying for non-RED exceptions per center
Figure 2: Within-region variability in non-RED approvals between centers with at least 20 applications
Disclosures: The following people have nothing to disclose: David S. Goldberg, George A. Makar, Benjamin French