Center variation in the use of nonstandardized model for end-stage liver disease exception points

Authors

  • David S. Goldberg,

    Corresponding author
    1. Division of Gastroenterology, Department of Medicine, Philadelphia, PA
    2. Clinical Center for Epidemiology and Biostatistics, Perelman School of Medicine, Philadelphia, PA
    • Address reprint requests to David S. Goldberg, M.D., M.S.C.E., Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Division of Gastroenterology, 9 Penn Tower, Philadelphia, PA 19104 19104. Telephone: 215-349-8222; FAX: 215-349-5915; E-mail: david.goldberg@uphs.upenn.edu

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  • George Makar,

    1. Division of Gastroenterology, Department of Medicine, Philadelphia, PA
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  • Therese Bittermann,

    1. Department of Medicine, University of Pennsylvania, Philadelphia, PA
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  • Benjamin French

    1. Clinical Center for Epidemiology and Biostatistics, Perelman School of Medicine, Philadelphia, PA
    2. Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA
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  • The authors have no conflicts of interest to disclose.

  • See Editorial on Page 1287

Abstract

The Model for End-Stage Liver Disease (MELD) score is an imperfect prognosticator of waitlist dropout, so transplant centers may apply for exception points to increase a waitlist candidate's priority on the waitlist. Exception applications are categorized as recognized exceptional diagnoses (REDs; eg, hepatocellular carcinoma) and non-REDs (eg, cholangitis). Although prior work has demonstrated regional variation in the use of exceptions, no work has examined the between-center variability. We analyzed all new waitlist candidates from February 27, 2002 to June 3, 2011 to explore variations in the use of non-REDs, for which no strict exception criteria exist. There were 58,641 new waitlist candidates, and 4356 (7.4%) applied for a non-RED exception. The number of applications increased steadily over time, as did the approval rates for such applications: from <50% in 2002 to nearly 75% in 2010. When we adjusted for patient factors, there was significant variability (P < 0.001) in the use of non-RED exceptions in 8 of 11 United Network for Organ Sharing (UNOS) regions and in the approval of these exceptions in 6 of 11 UNOS regions. The variability in the use and approval of non-REDs was clinically significant: waitlist candidates with approved exceptions were significantly more likely to undergo transplantation (68.3% versus 53.4%, P < 0.001) and were less likely to be removed for death or clinical deterioration (10.4% versus 16.2%, P < 0.001). Increased median MELD score at transplantation within a donor service area was the only center factor associated with increased odds of applying for exceptions, while no center factors were associated with having non-RED exceptions approved. Further work is needed to identify other sources of variation to ensure the appropriate and equitable use of non-RED exceptions. Liver Transpl 19:1330–1342, 2013. © 2013 AASLD.

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