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