Outcomes of incoming and outgoing second opinions from a UK liver transplant centre

Abstract

ObjectiveSecond transplant centre opinions (STCOs) for patients declined for liver transplantation are infrequent. We aimed to identify STCOs outcomes from a tertiary transplant centre.DesignReferrals between 2012 and 2020 to Birmingham Unit were reviewed. Incoming: all referrals from out-of-region centres were collated. Outgoing: patients not listed in Birmingham were reviewed to identify referrals for STCOs to the other UK centres (A–F).Results2535 patients were assessed for liver transplantation during the study period. Incoming: among 1751 referrals, 23 STCOs (17 unit A, 3 unit B, 1 unit C, 1 unit D and 1 unit E) were provided by Birmingham. Of the STCOs, 13/23 (57%) patients remained unsuitable for transplantation. Therefore, 10/23 (43%) underwent a second liver transplant assessment, of whom five (50%) were still deemed unsuitable, three (30%) listed (one transplanted) and two (20%) died preassessment. Outgoing: among 426 patients not listed, eight (1.8%) patients were referred for STCO (4 unit E, 2 unit B, 1 unit D, 1 unit A). Three (38%) were listed, two (25%) were assessed and declined, two (25%) were unsuitable for assessment and one (12.5%) died while waiting. Combining incoming and outgoing Birmingham STCOs (n=31), six (19%) of STCOs were listed in a second centre.ConclusionSecond transplant centre opinions are rare with the majority still deemed unsuitable for liver transplantation. This highlights potential resource implications especially when undergoing a full second formal assessment. A streamlined STCO process with sharing of investigations and use of telemedicine in appropriate patients may allow for greater transparency, quicker decision making and less use of labour-intensive resources.

National survey of second opinions for hospitalized patients in need of liver transplantation

“…In the United Kingdom, 1 study demonstrated that virtual, multidisciplinary discussions between transplant programs is feasible, may negate the need for patient travel, and can be performed in an expedited fashion. [11] However, virtual discussions based on the first center's experience may unduly influence or bias the second center. For more nuanced decisions, such as psychosocial evaluations, 1 potential solution may be to conduct virtual specialtyrelevant evaluations by the second center prior to transfer.…”

“…The ability to share medical testing results and committee decisions may allow for pre-transfer screening protocols and save on health care and administrative costs associated with transfer and re-evaluation. In the United Kingdom, 1 study demonstrated that virtual, multidisciplinary discussions between transplant programs is feasible, may negate the need for patient travel, and can be performed in an expedited fashion 11 . However, virtual discussions based on the first center’s experience may unduly influence or bias the second center.…”