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Abbreviations
- HCC
hepatocellular carcinoma
- MELD
Model for End‐Stage Liver Disease
- OPTN
Organ Procurement and Transplantation Network
Key Points
The eight‐region redistricting proposal failed to address access to care, organ usage, and donation rates.
The use of Model for End‐Stage Liver Disease exception points, and not geography, is the major factor contributing to disparities in transplant.
Establishment of a national review board, adjustment of hepatocellular carcinoma exception points to reflect true wait‐list mortality, and efforts to improve organ utilization should precede changes in the model for organ distribution.
The U.S. Department of Health and Human Services implemented the Final Rule in March 2000, which establishes a regulatory framework for the structure and operations of the Organ Procurement and Transplantation Network (OPTN). This document stated that fair allocation of organs should not be based on the “candidate's place of residence or place of listing.”1 However, disparities in organ allocation exist. At the same time, differences in waiting‐list mortality, organ donation rates, and use of exception points mar attempts to analyze or correct those disparities. In 2016, the OPTN “redistricting” proposal aimed to make liver distribution more equitable in the United States by creating eight regions.2 However, changing the geographic areas of liver distribution without addressing other elements of disparity will not solve the problem. The use of Model for End‐Stage Liver Disease (MELD) exception points, not geography, is a major factor contributing to disparities in organ allocation, and the prior OPTN proposal failed to adequately address this. It also did not discuss overall access to transplant care, organ usage, and donation rates.
MELD Exception Points
The redistricting proposal is based on the premise that MELD score at time of transplant is an accurate surrogate for waiting‐list mortality. However, with the current widely variable and often excessive usage of MELD exception points, this is not the case. Exception points were designed to reflect disease severity and transplant need for patients who are underserved by laboratory MELD scores. Unfortunately, there is wide variation in the use of exception points between regions (Fig. 1).3 For example, in 2015, 21% of patients listed for transplant in region 6 had nonstandard MELD exception points compared with only 5.7% of patients in region 3.4 Currently, death on the wait list occurs approximately five times more often for patients without exception points than for those with exception points.5 Transplant candidates without MELD exception points wait longer for a transplant and are less likely to be transplanted. Between 2005 and 2012, 79% of patients with exception points underwent liver transplant compared with only 40% of patients without exception points.5 Most exception points are allotted to patients with hepatocellular carcinoma (HCC). Within this population, advanced locoregional therapies have established a large and stable cohort of patients who are actually less likely to die while on the wait list than their non‐HCC counterparts.6 A recent proposal to form a National Liver Review Board will hopefully decrease exception point variability and should be implemented prior to redistricting.4
Figure 1.
(Left) Percentage of transplant recipients with exception points by region (2012‐2014). Median Lab Model for End‐Stage Liver Disease at transplant by region (2012‐2014). Reprinted with permission from Clinical Liver Disease.10 Copyright 2016, American Association for the Study of Liver Diseases.
Disparities in Access
Access to health care, from availability of physicians to presence of hospital beds, also varies nationwide, and this is mirrored in access to transplant centers.7, 8 Physical distance to a transplant center matters. In all United Network for Organ Sharing regions, rural residents are less likely to be wait‐listed than urban dwellers. Even when they do have a position on the wait list, they are still less likely to receive a transplant.9 Redistricting changes how organs are distributed to a transplant center, but it does not improve an individual's access to the transplant center.
Organ Usage
An additional concern is the optimal utilization of organs. Regional availability of organs differs based on multiple factors, including eligible deaths, organ procurement organization performance, and variable organ donation rates.10 Decisions about the use of an organ are made by the individual transplant center, without national or regional consensus.7 Consequently, more than 20% of donations after cardiac death status organs and more than 10% of hepatitis C virus–positive organs are recovered but not transplanted.7 These organs represent a pool of resources that could be tapped with improved organization.
Liver‐Simulated Allocation Model
Finally, the liver‐simulated allocation model predicts that, with implementation of the new redistricting proposal, there will be approximately 2% fewer transplants overall and an increase in organ transport costs.2, 11 The cost of each transplant would increase by US $4,980.11 Although total Medicare spending may decline, this prediction was based on past health care reimbursements and cannot predict future spending behaviors.
Conclusions
The crux of the problem is that attempts to merely alter the geographic areas of liver distribution to equalize MELD scores may not have a meaningful impact on organ access disparities where they matter most—among patients at risk for dying while on the wait list. A more efficacious proposal would address the standardization of exception points, improve access to transplant centers, optimize use of available organs, and then consider larger expansion of distribution. The current OPTN proposal, which includes the implementation of a national review board for exception points and more modest geographic changes, represents a step in the right direction.4, 12
Potential conflict of interest: Nothing to report.
References
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