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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
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