Preliminary results of a liver allocation plan using a continuous medical severity score that de-emphasizes waiting time

Liver allocation remains problematic because current policy prioritizes sta tus 2B or 3 patients by waiting time rather than medical urgency. On Februa ry 21, 2000, we implemented a variance to the United Network for Organ Shar ing liver allocation policy that redefined status 2A by much more rigid, de finable criteria and prioritized status 2B patients by using a continuous m edical urgency score based on the Child-Turcotte-Pugh score and other medic al conditions. In this system, waiting time is used only to differentiate s tatus 2B candidates with equal medical urgency scores. Comparing the 6-mont h period (period 1; n = 67) before implementation of this system to the 6-m onth period after implementation (period 2; n = 75), there was a significan t reduction in the number of transplantations performed for patients listed as status 2A (46.3% to 14.7%; P =.002) and an increase in the number of pa tients listed as status 2B who received transplants (44.8% to 70.7%; P =,10 ). Most dramatically, there was a 37.1% reduction in overall deaths on the waiting list from 94 deaths in period 1 to 62 deaths in period 2 (P =.005), with the most significant reduction for patients removed from this list at status 2B (52 v 18 patients; P =,04). There were 3 postoperative deaths in each period, with only 1 graft lost in period 2, Status 2B patients with t he greatest degree of medical urgency received transplants without multiple peer reviews requesting elevation to 2A status. We conclude that a continu ous medical urgency score system allocates donor livers much more fairly to those in medical need and reduces waiting list mortality without sacrifici ng efficacy.