Intraregional model for end‐stage liver disease score variation in liver transplantation: Disparity in our own backyard

Abstract

Variation in average Model for End-Stage Liver Disease (MELD) score at liver transplantation (LT) by United Network for Organ Sharing (UNOS) regions is well documented. The present study aimed to investigate MELD variation at the interregional, intraregional, and intra-donation service area (DSA) levels. Patients undergoing LT between 2015 and 2016 were obtained from the UNOS standard analysis and research file. The distribution of allocation MELD score including median, skew, and kurtosis was examined for all transplant programs. Intraregional median allocation MELD varied significantly within all 11 UNOS regions. The largest variation between programs was seen in region 5 (MELD 24.0 versus 38.5) and region 3 (MELD 20.5 versus 32.0). Regions 1, 5, and 9 had the largest proportion of programs with a highly negative skewed MELD score (50%, 57%, and 57%, respectively), whereas regions 3, 6, 10, and 11 did not have any programs with a highly negative skew. MELD score distribution was also examined in programs located in the same DSA, where no barriers exist and theoretically no significant difference in allocation should be observed. The largest DSA variation in median allocation MELD score was seen in NYRT-OP1 LiveOnNY (MELD score variation 11), AZOB-OP1 Donor Network of Arizona (MELD score variation 11), MAOB-OP1 New England Organ Bank (MELD score variation 9), and TXGC-OP1 LifeGift Organ Donation Ctr (MELD score variation 9). In conclusion, the present study demonstrates that this MELD disparity is not only present at the interregional level but can be seen within regions and even within DSAs between programs located as close as several city blocks away. Although organ availability likely accounts for a component of this disparity, the present study suggests that transplant center behavior may also play a significant role. Liver Transplantation 24 488-496 2018 AASLD.

State‐Based Liver Distribution: Broad Sharing With Less Harm to Vulnerable and Underserved Communities Compared With Concentric Circles

“…A sensitivity analysis showed the relative composition of the DSA waiting list and the general population based on the CHS score of residence to be highly correlated ( R 2 = 0.993), suggesting that changes seen based on wait‐list demographics are reflected in population demographics. Using previously published measures of wait‐list mortality, the 250/500 model would move an additional 349 organs into areas corresponding to the 3 OPTN regions with the lowest wait‐list mortality, taking 148 organs from the 3 regions with the highest mortality . In the 300/600 model, 406 organs would move to the lowest mortality regions with 237 organs leaving the highest mortality regions.…”

“…For each DSA, data from the Centers for Disease Control and Prevention were obtained for the number of deaths among persons age 15‐74 years with cause of death related to ESLD or hepatocellular carcinoma, as previously described . These county‐level data were aggregated to the DSA level.…”

“…For each DSA, data from the Centers for Disease Control and Prevention were obtained for the number of deaths among persons age 15-74 years with cause of death related to ESLD or hepatocellular carcinoma, as previously described. (17,18) These county-level data were aggregated to the DSA level. The number of adult liver transplant wait-list additions within the DSA was calculated on the basis of the SRTR data relative to adult liver disease deaths.…”

“…Using previously published measures of wait-list mortality, the 250/500 model would move an additional 349 organs into areas corresponding to the 3 OPTN regions with the lowest wait-list mortality, taking 148 organs from the 3 regions with the highest mortality. (17) In the 300/600 model, 406 organs would move to the lowest mortality regions with 237 organs leaving the highest mortality regions. In the statebased system, 120 organs would move to low mortality regions, at a loss of 3 organs from high mortality regions.…”

Think global, act local: Responsibility for the liver transplant candidate

“…The current issue of Liver Transplantation includes 2 articles that may enhance our understanding of the role of center behavior on both access to an organ and the implications of center practice on aMELD at the center, DSA, and regional level. Using skew and kurtosis as descriptors of the distribution of aMELD to 2 recent years of national data, Croome et al argue that these measures, whether viewed from the perspective of region, DSA, or center, provide a more informative and nuanced view of access to transplantation than just median aMELD . It may be presumed that centers within the same DSA would have a similar aMELD score distribution, given access to the same local donor pool.…”