Changing opportunities for liver transplant for patients with hepatocellular carcinoma

Zendel, Alex; Watkins, Randall; Moon, Andrew M.; Gerber, David A.; Barritt, A. Sidney; Desai, Chirag S.

doi:10.1111/ctr.14609

Cited by 3 publications

(3 citation statements)

References 13 publications

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“…A recent study looked at changes for patients with HCC 1 year before and after acuity circles was enacted and found that 6/11 UNOS regions had decreases in the absolute number of HCC transplants, with Regions 2 and 4 having statistically significant decreases in transplants for patients with HCC. [ 9 ] Our study provides novel data on the geographic variability in the impact of the policy changes in transplantation for patients with HCC. We provide a longitudinal view of changes for 16 years and four major eras.…”

Section: Discussionmentioning

confidence: 99%

Impact of major hepatocellular carcinoma policy changes on liver transplantation for hepatocellular carcinoma in the United States

Shah¹,

Chyou²,

Goldberg

2022

Liver Transpl

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Since its inception in 2002, Model for End-Stage Liver Disease (MELD)based allocation has undergone a series of revisions, especially with respect to exception points. Hepatocellular carcinoma (HCC) is the most common indication for MELD exceptions, and as a result of higher transplant proportions and lower waitlist mortality, a series of policy changes have been implemented to deprioritize HCC transplants. We examined the impact of HCC exception policy changes on transplant and waitlist mortality rates. We evaluated Organ Procurement and Transplantation Network/United Network for Organ Sharing data on adult patients from January 1, 2005, to June 4, 2021, focusing on waitlist mortality and deceased donor liver transplantation (DDLT) proportions. The data were divided into four policy eras: (1) MELD 22 points at waitlisting with an increase in points every 3 months (i.e., elevator) (January 2005-October 2015), (2) delay and cap at MELD 34 points (October 2015-May 2019), (3) delay and fixed exceptions based on donor service area (DSA) median MELD at transplantation minus three (MMaT-3; May 2019-February 2020), and (4) delay and fixed exceptions based on the MMaT-3 of centers within 250 nautical miles (i.e., acuity circles; February 2020-June 2021). We evaluated (a) changes in the proportions of DDLTs for patients with HCC exceptions within each era nationally and by DSA and (b) waitlist mortality in the three recent policy eras, focusing on mortality in the 6 months after the 6-month delay period. The percentage of adult DDLT with HCC exceptions decreased through the four eras: 22.9% (n = 14,049), 17.9% (n = 4598), 14.3% (n = 851), and 12.4% (n = 1425), respectively. Of the 51 DSAs analyzed, the annual percent change in DDLTs for patients with HCC exceptions was negative (i.e., decreased) in 47 (92.2%). Waitlist mortality remained stable. All HCC policy implementations led to a decrease in the SEE EDITORIAL ON PAGE 1821How to cite this article: Shah RH, Chyou D, Goldberg DS. Impact of major hepatocellular carcinoma policy changes on liver transplantation for hepatocellular carcinoma in the United States.

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Section: Discussionmentioning

confidence: 99%

Impact of major hepatocellular carcinoma policy changes on liver transplantation for hepatocellular carcinoma in the United States

Shah¹,

Chyou²,

Goldberg

2022

Liver Transpl

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“…[60] These differences by region stem from geographic variation in the MELD score needed to receive LT. [61] Although AC was predicted to decrease this geographic variation in MMaT, early studies suggest that AC has not accomplished this goal. [62,63] As we currently stand, for HCC patients within Milan Criteria with the same MELD exception points, there continues to be geographic variation in LT rates as a result of patients being listed in areas with very different MMaT.…”

Section: Geographic Disparities By Region and Neighborhood Hcc And Po...mentioning

confidence: 99%

Geographic disparities in access to liver transplantation

Yilma

Dalal

Wadhwani

et al. 2023

Liver Transplantation

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Since the Final Rule regarding transplantation was published in 1999, organ distribution policies have been implemented to reduce geographic disparity. While a recent change in liver allocation, termed acuity circles, eliminated the donor service area as a unit of distribution to decrease the geographic disparity of waitlisted patients to liver transplantation, recently published results highlight the complexity of addressing geographic disparity. From geographic variation in donor supply, as well as liver disease burden and differing model for end-stage liver disease (MELD) scores of candidates and MELD scores necessary to receive liver transplantation, to the urban-rural disparity in specialty care access, and to neighborhood deprivation (community measure of socioeconomic status) in liver transplant access, addressing disparities of access will require a multipronged approach at the patient, transplant center, and national level. Herein, we review the current knowledge of these disparities—from variation in larger (regional) to smaller (census tract or zip code) levels to the common etiologies of liver disease, which are particularly affected by these geographic boundaries. The geographic disparity in liver transplant access must balance the limited organ supply with the growing demand. We must identify patient-level factors that contribute to their geographic disparity and incorporate these findings at the transplant center level to develop targeted interventions. We must simultaneously work at the national level to standardize and share patient data (including socioeconomic status and geographic social deprivation indices) to better understand the factors that contribute to the geographic disparity. The complex interplay between organ distribution policy, referral patterns, and variable waitlisting practices with the proportion of high MELD patients and differences in potential donor supply must all be considered to create a national policy strategy to address the inequities in the system.

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“…From the perspective of transplant centers, another growing concern surrounding the new AC policy is increased cost and allocation of resources, with some studies finding an increase in cost and distance traveled between transplant and donor hospitals. [5][6][7][8][9] Knowledge about the satisfaction levels and perceptions among transplant surgery staff in the United States is lacking. Further delineation of geographic disparities in transplant metrics and the perceived impact of the AC among transplant surgeons is needed to better understand the strengths of the AC policy and to identify areas of improvement for future policy decision-making.…”

Section: Introductionmentioning

confidence: 99%

Perceptions and Early Outcomes of the Acuity Circles Allocation Policy Among Liver Transplant Centers in the United States

Pawlak

Song

Alvi

et al. 2022

Transplantation Direct

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Background. Recently, a new liver allocation policy called the acuity circles (AC) framework was implemented to decrease geographic disparities in transplant metrics across donor service areas. Early analyses have examined the changes in outcomes because of the AC policy. However, perceptions among transplant surgeons and staff regarding the new policy remain unknown. Methods. A 28-item survey was sent to division chiefs and surgical directors of liver transplantation across the United States. Questions assessed the respondents’ perceptions regarding center-level metrics and staff satisfaction. We used Organ Procurement and Transplantation Network data to study differences in allocation between the pre-AC implementation period (2019) and the post-AC implementation period (2020–2021). Results. A total of 40 participants completed this ongoing survey study. Most responses were from region 8 (13%), region 10 (15%), and region 11 (13%). Sixty-three percent of respondents stated that the wait time for a suitable offer for recipients with model of end-stage liver disease score <30 has decreased, whereas 50% stated that wait time for a suitable offer for recipients with model of end-stage liver disease score >30 has increased. However, most respondents (75%) felt that the average cost per transplant had increased and that the rate of surgical complications and 1-y graft survival had remained the same. In most states, an observable decrease in in-state liver transplantations occurred each year between 2019 and 2021. In addition, most allocation regions reported an increase in donations after circulatory deaths between 2019 and 2021. Conclusions. Perceptions of the new AC policy among liver transplant surgeons in the United States remain mixed, highlighting the potential strengths and concerns regarding its future impact. Further studies should assess the effects of the AC policy on clinical outcomes and liver transplantation access.

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Changing opportunities for liver transplant for patients with hepatocellular carcinoma

Cited by 3 publications

References 13 publications

Impact of major hepatocellular carcinoma policy changes on liver transplantation for hepatocellular carcinoma in the United States

Impact of major hepatocellular carcinoma policy changes on liver transplantation for hepatocellular carcinoma in the United States

Geographic disparities in access to liver transplantation

Perceptions and Early Outcomes of the Acuity Circles Allocation Policy Among Liver Transplant Centers in the United States

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