Center-level and region-level variations in liver transplantation practices following acuity circles policy change

Abstract

The Acuity Circles (AC) policy was implemented by the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) on February 4, 2020, with the goal of reducing variation in median Model for End-Stage Liver Disease (MELD) score at transplantation. A 2018 analysis by the Scientific Registry of Transplant Recipients (SRTR) predicted that AC would reduce variance in median MELD at transplant (MMAT) across donation service areas (DSAs), therefore reducing the geographical disparities present under Share 35. 1,2 However, the focus of analyses defining the 'success' of this policy has drawn on data at the national level (e.g., percentage of transplants within MELD categories or variance in MMAT), rather than changes in transplants at the local level (e.g., individual transplant centers).On a national level, the data suggest that the AC policy has been effective in achieving the goals of increasing access to transplant for patients with the highest MELD scores. 3 However, we reported in a 6-month preliminary study of AC that differences between individual centers and regions in the variance of MMAT may still be present

Geographic disparities in access to liver transplantation

“…In 1998, the Final Rule directed that organ allocation policies must not be based on LT candidates’ place of residence 3 . Before 2013, organs were first distributed at the donor service area (DSA) level, which resulted in wide variation in median MELD scores at transplant (MMaT) across DSAs 4 . Share 35 policy allowed broader sharing within Organ Procurement and Transplantation Network (OPTN) regions with the goal of reducing waitlist mortality for patients with the highest MELD scores 5 .…”

“…[3] Before 2013, organs were first distributed at the donor service area (DSA) level, which resulted in wide variation in median MELD scores at transplant (MMaT) across DSAs. [4] Share 35 policy allowed broader sharing within Organ Procurement and Transplantation Network (OPTN) regions with the goal of reducing waitlist mortality for patients with the highest MELD scores. [5] After Share 35, although this policy led to an increase in organ offers for those with allocation MELD ≥ 35, there was an overall decrease in organ acceptance rates with center and regional variations.…”

“…[8] Furthermore, preliminary findings suggest that there might be center and regional variations in deceased donor LT even after AC, with regions 2, 7, and 9 not seeing an increase in deceased donor LTs within the same allocation MELD category and 5 out of 12 centers in region 5 accounting for the largest increase in deceased donor LTs. [4] The number of organ donors in the United States has been increasing over the last few years through the use of extended criteria donors (ECDs). [9] As a result of the opioid epidemic, there has been an increase in the number of hepatitis C positive donors.…”

Progress in liver transplantation, but better access is needed

“…An initial analysis of this policy demonstrated improved access to transplant for the sickest patients, but this did not necessarily represent a national trend, as a small proportion of centers drove these results. [10] Transplant access has not increased uniformly across racial and ethnic groups over time, with the proportion of Black liver transplant candidates and recipients decreasing, Hispanic patients increasing, and all other groups remaining relatively stable. Numerous studies have now been published describing known inequities that result in Black patients being referred for transplant at lower rates than other racial and ethnic groups, which is likely a result of the long-standing effects of systemic racism on these patient populations.…”

“…Implementation of acuity circles for liver allocation sought to improve geographic disparities in MELD at the time of transplant. An initial analysis of this policy demonstrated improved access to transplant for the sickest patients, but this did not necessarily represent a national trend, as a small proportion of centers drove these results 10. Transplant access has not increased uniformly across racial and ethnic groups over time, with the proportion of Black liver transplant candidates and recipients decreasing, Hispanic patients increasing, and all other groups remaining relatively stable.…”