Projected survival benefit as criterion for listing and organ allocation in heart transplantation.

Background: Current policies for the selection of candidates and the allocation of hearts for transplantation give priority to patients at greatest risk if not transplanted. However, to achieve best use of the donated organs, it is necessary to estimate the net benefit associated with transplantation.

Methods: The survival benefit associated with being listed or not, with being transplanted or left on the waiting list, or with being transplanted or being denied the opportunity for a transplant can be estimated by means of time-to-event modeling of competing risks with intervening states.

Time-to-event modeling of competing risks with intervening states in transplantation.

The criteria for the selection of who among the persons on the waiting is to receive an organ that has become available and who is to be placed on the list to begin with are the most contentious issues in organ transplantation. The decisions of whom to list and whom to transplant should take into account the net benefit to the individual patient and to the affected group as a whole. We present a method to compute the survival benefit by means of fully parametric modeling of the competing events (transplantation, death while awaiting the transplant, removal for other reasons), taking into account the transplant as an intervening state on the path to death post-transplant, and apply it to decisions whether to list or not list and whether to transplant or to leave on the waiting list or to remove from the list.