Veterans Outcomes and Costs Associated With Liver Disease (VOCAL-Penn) Score Calculator

The VOCAL-Penn (Veterans Outcomes and Costs Associated with Liver Disease-Penn) Score is a contemporary and highly accurate clinical tool designed specifically to predict postoperative mortality and decompensation in patients with cirrhosis. Developed in 2020 through a collaboration between the Department of Veterans Affairs and the University of Pennsylvania, it was created to overcome the limitations of older models like the MELD and Child-Pugh scores, which were originally designed to predict survival in non-surgical contexts (Mahmud et al., 2021).

Unlike previous models, the VOCAL-Penn score accounts for the type and urgency of the surgery, which are often the most significant drivers of outcome in patients with advanced liver disease.

The Core Components of the VOCAL-Penn Score

The model utilizes nine clinical and surgical variables to generate risk estimates. By incorporating surgical category and indication, it provides a more granular assessment than purely biochemical models.

1. Patient-Related Factors

• Age: Progressive increase in risk with advancing age.
• Preoperative Albumin: A critical marker of the liver’s synthetic function and nutritional status.
• Total Bilirubin: Reflects the liver’s excretory capacity.
• Platelet Count: Serves as a surrogate marker for portal hypertension and hypersplenism.
• BMI $\ge$ 30: Obesity is factored into the calculation.
• Fatty Liver Disease (MASLD): Specific points are assigned if the etiology is metabolic dysfunction-associated steatotic liver disease.

2. Surgical-Related Factors

• Emergency Indication: Whether the surgery is elective or emergent.
• ASA Classification: The American Society of Anesthesiologists Physical Status (typically grades 2, 3, or 4).
• Surgical Category: The model categorizes non-hepatic surgeries into six distinct groups:
  1. Abdominal (Open or Laparoscopic): e.g., cholecystectomy, colectomy.
  2. Abdominal Wall: e.g., hernia repairs.
  3. Chest/Cardiac: e.g., CABG or valve replacement (excluding TAVR).
  4. Major Orthopedic: e.g., total hip/knee arthroplasty.
  5. Vascular: e.g., peripheral bypass or aneurysm repair.

Predictive Accuracy and Outcomes

The VOCAL-Penn score provides estimates for three specific time horizons and one clinical complication:

• 30-day mortality
• 90-day mortality
• 180-day mortality
• 90-day decompensation risk (e.g., development of ascites, encephalopathy, or variceal bleeding).

Superiority Over MELD and Mayo Scores

Validation studies have shown that the VOCAL-Penn score significantly outperforms older models. In the original derivation study, the C-statistic (a measure of accuracy) for 30-day mortality was 0.86, compared to 0.77 for the Mayo Risk Score and 0.72 for the MELD score (Mahmud et al., 2021).

Clinical Application

The VOCAL-Penn score is currently recommended by many professional societies as the preferred tool for preoperative risk stratification in cirrhosis.

• High-Risk Thresholds: Patients with high predicted mortality (e.g., $> 15\%$) are often reconsidered for non-surgical management or referred for a liver transplant evaluation before elective procedures.
• Accessibility: The score is widely available through an online calculator (www.vocalpennscore.com), making it easy to use during a bedside consult.

Notable Exclusions

It is important to note that the score is not validated for:

• Liver-specific surgeries (e.g., partial hepatectomy).
• Endovascular valve replacements (TAVR).
• Liver transplantation itself.

References

1. Mahmud, N., et al. (2021). Risk prediction models for post-operative mortality in patients with cirrhosis. Hepatology, 73(1), 204-218. https://doi.org/10.1002/hep.31558
2. Mahmud, N., et al. (2021). External validation of the VOCAL-Penn cirrhosis surgical risk score in 2 large, independent health systems. Liver Transplantation, 27(7), 961-970. https://doi.org/10.1002/lt.26060
3. Kaplan, D. E., et al. (2020). Novel risk prediction models for postoperative mortality in patients with cirrhosis. Hepatology.
4. Serper, M., et al. (2022). Inpatient Gastroenterology Consultation and Outcomes of Cirrhosis-Related Hospitalizations in Two Large National Cohorts. Digestive Diseases and Sciences.