LUNG TRANSPLANTATION Overall ISHLT 2008 J Heart Lung Transplant 2008;27: 937-983.
Josef Stehlik, MD, MPH Associate Professor of Medicine Medical Director, Heart Transplant Program...
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Transcript of Josef Stehlik, MD, MPH Associate Professor of Medicine Medical Director, Heart Transplant Program...
Josef Stehlik, MD, MPHAssociate Professor of Medicine
Medical Director, Heart Transplant ProgramUniversity of Utah School of MedicineDirector, ISHLT Transplant Registry
No financial relationships to disclose.
Are DT / BTT designations still relevant?
Are DT / BTT designations still relevant?
• The answer may depend on who is asking
1. Payer (health insurance)
2. Provider (advanced heart failure team)
3. Patient
1. Payer perspective
• VAD indication important for eligibility determination and for budgeting
Payer view
• (Increasing number of) private insurers - declare indication as BTT vs DT - BTT patients must be listed for transplant before VAD implant
• (Some) state Medicaid programs - no BTT durable MCS
• VHA - federal insurer - ‘… heart failure treatment utilizing a VAD or total artificial heart …’
2. Provider perspective (us)
2008-2011
Wever-Pinzon O, Stehlik J. Circulation 2013 Jan 29;127(4)
Waiting list mortality
Transplant rate
Colvin-Adams M. AJT 2014
UNOS Status
Transplanted in status
Median waiting time
1A
1B
2
64%
31%
5%
78 days
224 days
618 days
Stehlik J, Stevenson LW, Mehra MR.JHLT Oct 2014
• Is this a scientific / clinical care proposition or rather expression of desperation?
Are DT / BTT designations still relevant?
Proposed revision of US heart allocation
Meyer DM, AJT 2014
3. Patient perspective
• 22-year old patient
Expected survival – 22 year old male
99.4% 99.0%
National Vital Statistics Reports. 58 (21), 2010
Clinical scenario
• 22-year-old• Non-ischemic CM• NYHA IV / Stage D, now inotrope dependent
Expected survival
Expected survival – heart transplant
Expected survival – DT VAD
Data courtesy of Kirklin JK, Naftel DC
Expected survival - BTT VAD
Data courtesy of Kirklin JK, Naftel DC
Expected survival - BTT VAD
Data courtesy of Kirklin JK, Naftel DC
Are DT / BTT designations still relevant?
• Payer - relevant for budgeting (eligibility determination, reimbursement)
• Provider - prefer the flexibility of adjusting strategy based on circumstances
• Patient - does not care about our terminology - wants to know the options and likely outcomes to make informed decisions