Volk Michael L, Goodrich Nathan, Lai Jennifer C, Sonnenday Christopher, Shedden Kerby
Division of Gastroenterology and Transplantation Institute, Loma Linda University, Loma Linda, CA.
Arbor Research Collaborative for Health, Ann Arbor, MI.
Liver Transpl. 2015 Jun;21(6):784-91. doi: 10.1002/lt.24113. Epub 2015 Apr 23.
Organ offers in liver transplantation are high-risk medical decisions with a low certainty of whether a better liver offer will come along before death. We hypothesized that decision support could improve the decision to accept or decline. With data from the Scientific Registry of Transplant Recipients, survival models were constructed for 42,857 waiting-list patients and 28,653 posttransplant patients from 2002 to 2008. Daily covariate-adjusted survival probabilities from these 2 models were combined into a 5-year area under the curve to create an individualized prediction of whether an organ offer should be accepted for a given patient. Among 650,832 organ offers from 2008 to 2013, patient survival was compared by whether the clinical decision was concordant or discordant with model predictions. The acceptance benefit (AB)--the predicted gain or loss of life by accepting a given organ versus waiting for the next organ--ranged from 3 to -22 years (harm) and varied geographically; for example, the average benefit of accepting a donation after cardiac death organ ranged from 0.47 to -0.71 years by donation service area. Among organ offers, even when AB was >1 year, the offer was only accepted 10% of the time. Patient survival from the time of the organ offer was better if the model recommendations and the clinical decision were concordant: for offers with AB > 0, the 3-year survival was 80% if the offer was accepted and 66% if it was declined (P < 0.001). In conclusion, augmenting clinical judgment with decision support may improve patient survival in liver transplantation.
肝移植中的器官供体选择是高风险的医疗决策，很难确定在患者死亡前是否会有更好的肝脏供体出现。我们假设决策支持可以改善接受或拒绝的决策。利用器官移植受者科学登记处的数据，为2002年至2008年的42857名等待名单患者和28653名移植后患者构建了生存模型。将这两个模型中每日经协变量调整的生存概率合并为5年曲线下面积，以对特定患者是否应接受器官供体进行个体化预测。在2008年至2013年的650832次器官供体中，根据临床决策与模型预测是否一致，比较了患者的生存率。接受益处（AB）——接受给定器官与等待下一个器官相比预测的生命增益或损失——范围为3至-22年（损害），且存在地域差异；例如，按捐赠服务区划分，接受心脏死亡后器官捐赠的平均益处为0.47至-0.71年。在器官供体中，即使AB>1年，接受供体的情况也仅占10%。如果模型建议与临床决策一致，从器官供体时起患者的生存率会更高：对于AB>0的供体，接受供体时3年生存率为80%，拒绝时为66%（P<0.001）。总之，通过决策支持增强临床判断可能会提高肝移植患者的生存率。
