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Miles away from home? The new lung transplant CAS

By April 07, 2023No Comments

In March 2023 a new policy for matching lung transplant candidates with organs came into effect in the US. The new Composite Allocation Score (CAS), which replaces the previous Lung Allocation Score system (LAS), considers the multiple factors in establishing a suitable organ match to produce a single score for each lung transplant candidate.

Whilst the previous LAS system prioritised allocation of lungs to candidates with the highest score located within a 250–nautical mile radius from the donor hospital the new CAS system aims to improve equity in organ allocation by eliminating hard geographic boundaries. The use of arbitrary cut-off points under the LAS system previously led to allocation of organs to candidates with lower medical priority who lived inside the geographical boundary over candidates with greater priority who lived just outside the boundary. In comparison, the CAS considers geographic proximity of donor and transplant centers in relation to other key factors in organ allocation, minimizing the role of geography in allocation of organs. Furthermore, the CAS takes into account the proximity and travel efficiency between the donor hospital and the candidate’s transplant centre – not the location of the transplant candidate’s place of residence. 

Will CAS lead to more lung transplant patients long distances from their transplant centre?

It is expected that the CAS system will enable the sickest candidates broader geographic access to donor lungs. But how will the change impact the geographical spread of patients managed by an individual lung transplant centre? In the immediate term, removing the 250-mile cut off rule should enable greater access to organs for patients in rural or remote locations. Whilst this is a positive step for geographic equality of access to lungs, it can create additional considerations for clinicians managing ongoing delivery of patient care after transplantation. And in the longer term how will the change impact patients’ choice of lung transplant centre, given the shortage of donors in comparison to the waiting list? This remains to be seen, but it is possible that in order to maximize the chance of a match patients may be inclined to select programs considerable distances from their home location. 

The challenge of delivering specialist lung transplantation care across wide geographies

Receiving a lung transplant is a wonderful life-saving gift, but it’s not the end of a patient’s journey. The relationship between recipient and their transplant time is life-long, and ongoing care to avoid the risk of complications like rejection usually requires patients to attend their transplant center at 3 month intervals. The demands of follow-care can therefore be particularly burdensome for patients living long distances away. With a potential increase in the geographic spread of patients being managed by a single center following the introduction of the CAS, providers may wish to consider how to meet the challenge of delivering long term follow up care for patients based many miles away.

Digital health technology can remove geographical barriers to care access for patients, reducing the need for physical clinic attendance whilst enabling rapid triage at the first sign of potential complications. At patientMpower we have developed a specialised digital health platform for the remote monitoring of patients after lung transplantation. The technology combines clinical grade monitoring of objective parameters including spirometry, blood pressure, oximetry and body weight plus subjective measures like dyspnoea. Automated alerts inform the clinical team of changes in patient’s physiological status, whilst inbuilt spirometry quality control means clinicians can have full confidence in home monitoring data.

Reducing need for clinic visits by up to 66%

Use of patientMpower technology at NYU Langone Health lung transplant centre has resulted in a 66% reduction in the need for out-patient visits, enabling the specialist team to deliver patient-centred care for recipients based over a thousand miles away. In Ireland, use of patientMpower technology at the National  Lung Transplant Centre enabled a 40% reduction in clinic visits and in the UK a RCT to fully evaluate the benefits of a 50/50 clinic and virtual hybrid approach to care after lung transplantation care is ongoing. It is expected that this will demonstrate favorable patient outcomes with a reduction in resources, releasing clinicians’ capacity for better care prioritization. 

The technology is also used to remove barriers to care for various chronic respiratory conditions that can lead to the need for transplantation. For example, improving care access for rural patients is the specific goal of the patientMpower enabled remote monitoring program running at Indiana University’s ILD center. Use of digital technology can also aid shared care between pulmonary and transplant specialists in the pre-transplant period, and enable a smoother transition of care following transplant.

If you are considering new approaches to delivering care for patients with lung transplant don’t hesitate to get in touch to learn more: