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