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Proposal to Delay the HCC Exception Score Assignment

Proposal to Delay the HCC Exception Score Assignment. Liver and Intestinal Organ Transplantation Committee Spring 2014. The Problem. Candidates with HCC exceptions receive high priority on the waiting list Scores may increase automatically every three months

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Proposal to Delay the HCC Exception Score Assignment

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  1. Proposal to Delay the HCC Exception Score Assignment Liver and Intestinal Organ Transplantation Committee Spring 2014

  2. The Problem • Candidates with HCC exceptions receive high priority on the waiting list • Scores may increase automatically every three months • Most patients treated (90%), many with stable tumors • HCC: Significantly lower dropout rates than non-HCC • How to even out transplant rates for HCC vs non-HCC?

  3. Overall Dropout Rates for HCC and Non-HCC Candidates: Listed 4/14/04-12/31/07 p < 0.0001

  4. % Dropout within 12 Months: HCC and Non-HCC Candidates by RegionCandidates Added 7/1/08 – 6/30/11

  5. The Final Rule: 42 CFR Part 121October 20, 1999 • §121.8 of the Final Rule states that allocation policy should be based on “objective and measurable medical criteria, for patients or categories of patients who are medically suitable candidates for transplantation to receive transplants” • Waiting time should be de-emphasized • Patients should be rank ordered according to severity of disease and predicted mortalityon the liver list

  6. Goal of the Proposal • The proposed solution will address the disparities in transplant/drop-out rates between patients with HCC exceptions and those without by delaying the HCC score assignment

  7. Proposed Solution • Currently, as long as the candidate meets criteria, the initial score assignment is 22, followed by increases every 3 months

  8. Supporting Evidence • LSAM modeling: delay led to similar transplant rates between HCC and non-HCC • At least in regions with lower waiting times • Study by Halazun, et al: Recipients with HCC exceptions have worse outcomes in regions with shorter waiting times • “Biologic test” not met due to rapid transplantation

  9. Transplant Rates by HCC StatusLSAM Modeling Results

  10. What Members will Need to Do • Understand changes in the score assignment • For HCC cases submitted as “Other, specify”: will be monitored by the Committee

  11. Questions? • David C. Mulligan, MD Committee Chair david.mulligan@yale.edu • Name Region # Representative Email • Committee Liaison

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