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

Abstract

Allocation of livers for transplantation faces regulatory pressure to move toward broader sharing. A current proposal supported by the United Network for Organ Sharing Board of Directors relies on concentric circles, but its effect on socioeconomic inequities in access to transplant services is poorly understood. In this article, we offer a proposal that uses the state of donation as a unit of distribution, given that the state is a recognized unit of legal jurisdiction and socioeconomic health in many contexts. The Scientific Registry of Transplant Recipients liver simulated allocation model algorithm was used to generate comparative estimates of regional transplant volume and the impact of these considered changes with regard to vulnerable and high‐risk patients on the waiting list and to disparities in wait‐list access. State‐based liver distribution outperforms the concentric circle models in overall system efficiency, reduced discards, and minimized flights for organs. Furthermore, the efflux of organs from areas of greater sociodemographic vulnerability and lesser wait‐list access is more than 2‐fold lower in a state‐based model than in concentric circle alternatives. In summary, we propose that a state‐based system offers a legally defensible, practical, and ethically sound alternative to geometric zones of organ distribution.

Reply

“…We note that the Scientific Registry of Transplant Recipients (SRTR) considers liver simulated allocation model (LSAM) projections regarding the direction of the change in organ availability to be reliable . In this, our results were highly concordant with those of the SRTR, so the effect of this new policy on impoverished areas with high wait‐list mortality and lesser wait‐list access is beyond dispute—massive reductions in organ availability . This also comports with common sense when looking at SRTR‐generated maps of organ redistribution.…”

A Share 21 model in liver transplantation: Impact on waitlist outcomes

“…An increase in the threshold MELD‐Na score for sharing has been proposed by numerous groups modeling different allocation systems 24‐26. Hirose, in a recent editorial states, one “… proposal that absolutely makes sense and is strongly supported by data is the notion that the lower threshold to go to broader distribution should be increased from a historical MELD score of 15 to a current MELD‐Na score of 20.”27 Here, we propose a change specifically in the share rule among lower MELD‐Na score categories and we provide 2 succinct reasons.…”

Importance of incorporating standardized, verifiable, objective metrics of organ procurement organization performance into discussions about organ allocation

“…Much of the current, contentious debate on organ allocation relies on the premise that there are fundamental (i.e., nonmodifiable) differences in organ availability across the United States . In other words, some claim that a primary determinant of geographic inequality in access to transplant is inherent differences in donor deaths .…”