New on MDCalc: The VOCAL-Penn Score for Cirrhosis Surgical Risk

Every hepatologist knows the scenario. A patient with cirrhosis needs surgery and the existing risk tools give you three different answers, none of which quite match what your clinical instincts are telling you.

That is exactly the problem Dr. Nadiem Mahmud set out to solve. In the latest episode of MD Aware: Upgrading Clinical Judgment, host Dr. Shazia Siddique sits down with Dr. Mahmud, a transplant hepatologist and physician scientist at the University of Pennsylvania, to walk through his newly launched tool on MDCalc: the VOCAL-Penn Score.

Listen to the Episode

Meet the Guest

Dr. Nadiem Mahmud is an Assistant Professor of Medicine in the Division of Gastroenterology and Hepatology at the University of Pennsylvania. He developed the VOCAL-Penn Score out of a genuine clinical need he encountered repeatedly during his fellowship on the liver consult service, where existing tools consistently produced estimates that felt either overly alarming or simply out of step with patient reality.

What the VOCAL-Penn Score Does

The score takes nine inputs, including age, liver function tests, BMI, etiology of liver disease, ASA score, surgical urgency, and crucially, the category of surgery, and generates four distinct predictions: postoperative mortality risk at 30, 90, and 180 days, plus the risk of cirrhosis decompensation within 90 days. The inclusion of surgery type was a deliberate departure from older tools, and one of the key reasons the score performs so differently in practice.

Designed for Real Shared Decision-Making

One of the most important aspects of the VOCAL-Penn Score is what it is not designed to do. Dr. Mahmud is clear that there is no single threshold beyond which surgery should be universally ruled out. Patient values, symptom burden, and clinical judgment all remain central to the conversation. The score exists to inform that conversation, not replace it. One practical guideline he does offer: a projected 90-day mortality risk above 15% should prompt consideration of a preoperative liver transplant evaluation for eligible patients.

A Tool Built Around the Clinician Experience

With more than 50,000 annual users worldwide and endorsement from both the American College of Gastroenterology and the European Association for the Study of Liver Disease, the VOCAL-Penn Score has already seen remarkable adoption. Dr. Mahmud credits much of that to design decisions made early in the development process, keeping inputs to what is routinely available, ensuring the outputs are intuitive, and building the tool around the real workflow of a clinician under pressure.

Now on MDCalc

The VOCAL-Penn Score is now available on MDCalc, bringing it to the platform trusted by 1.3 million US clinicians and four out of five practicing physicians in the country. If you are caring for patients with cirrhosis who are being considered for surgery, this is a tool worth knowing.

About MD Aware: Upgrading Clinical Judgment is MDCalc's podcast dedicated to breaking down the science behind clinical scores and bringing transparency and confidence to your clinical workflow.