The new lottery ticket: Share 35

Abstract

Although regional sharing for liver transplantation for acute liver failure has been accepted for more than 25 years, (1) its extension to decompensated cirrhosis has only more recently become widely adopted. (2) In the current issue of Liver Transplantation, Edwards et al. (3) detail the results of the first 2 years of Share 35 following its implementation by the United Network for Organ Sharing. As anticipated, a greater number of candidates underwent transplantation in the Model for End-Stage Liver Disease (MELD)/Pediatric End-Stage Liver Disease (PELD) 351 category, with minimal changes in posttransplant mortality, graft survival, and access for pediatric and minority patients. (4) So, should we, as do the authors, endorse the current, or an even wider implementation of this strategy?First, historical precedent suggests that regional organ sharing does not reduce wait-list mortality. Share 35 is not the first effort in regional sharing for high-MELD candidates. Region 8 implemented an even broader sharing agreement for a 4-year time interval (2007)(2008)(2009)(2010)(2011), sharing regionally for MELD 291 candidates. (5) An analysis of the data from this experience indicated that there was no overall reduction in wait-list mortality. Mortality reduction in the smaller group of higher MELD patients was offset by increased mortality of the much larger group of lower MELD patients. In addition, there was a marked increase in travel time and associated costs, without a net benefit.Second, the financial implications of expanded organ sharing are significant and are not assessed in the report. A limitation of the analyses performed to date has been that they have only considered that a regional share involves additional air charter expense compared with the cost of a local donor. (6,7) In fact, for many, including in our donor service area (DSA), the standard acquisition cost for a regional donor is double that of a local donor because not only is travel cost increased, but the rules by which organ procurement organizations (OPOs) operate lead to markedly increased charges for liver donors harvested from outside the DSA. (7) This calculation does not consider the significantly increased human capital expenditure for regional shares compared with a local donor or how increased travel introduces increased risk to the transplant teams. (8,9) There has been modeling to suggest that broader sharing would result in "minimal overall system cost" because sicker patients would be transplanted earlier.The first problem is that our system does not allow for savings in pretransplant care to accrue to transplant centers to offset significant increases in costs for transplantation and posttransplant care. This is a lofty idea, but even if it turned out to be true, we have no mechanism to allocate cost savings, for example, from an insurance carrier to the potential transplant center to offset policy-associated increases to overhead costs. Additionally, our allocation system is dynamic, and with Share 35, the number of people wai...

Same policy, different impact: Center‐level effects of share 35 liver allocation

“…This finding was true across all regions and suggests that regional sharing patterns typically involve regional utilization of a liver for a decompensated patient with aMELD ≥35, rather than for a local decompensated patient with a calculated laboratory MELD <35. It will be important to understand whether these regional allocations result in livers being distributed to patients with significant differences in MELD; a difference of a small number of MELD points may not have prognostic value in outcome (21, 22). …”

“…It will be important to understand whether these regional allocations result in livers being distributed to patients with significant differences in MELD; a difference of a small number of MELD points may not have prognostic value in outcome. (21,22) Over 30% of patients transplanted with aMELD 35 did not maintain a TOT laboratory MELD 35, yet patients with aMELD 35 by HCC exception accounted for only 2.6% of the aMELD 35 transplants performed post-Share 35. It is therefore unlikely that the recently enacted HCC exception score cap of 34 will significantly affect the findings reported in this study.…”

“…As data on the impact of Share 35 matures, the liver transplant community will benefit from ongoing analysis and optimization of sharing policies, especially those that balance the competing interests of preservation of outcomes and cost with maximizing organ utility, reducing wait-list mortality, and minimizing center and regional disparities in access. (22,28) Center-level effects are harder to study than national effects, but because patients are transplanted at centers, center-level effects are determinative of patients' experiences with policy change. An understanding of the center-level changes that occur with policy implementation must be considered carefully at the time of policy debate and studied afterward to assure that such changes translate into the desired outcomes.…”

Effects of the Share 35 Rule on Waitlist and Liver Transplantation Outcomes for Patients with Hepatocellular Carcinoma

“…Initial publications looking at the overall effects of “Share 35” demonstrated no reduction in wait list mortality in the 2 years following its implementation [2,3]. When a subanalysis was performed looking at patients with MELD ≥ 35, a reduction of 90 day waitlist mortality (66% versus 59%) was observed.…”

“…When a subanalysis was performed looking at patients with MELD ≥ 35, a reduction of 90 day waitlist mortality (66% versus 59%) was observed. While this reduction was heralded as an encouraging result, some authors have stressed that the effects of any policy change must be examined for all patients awaiting LT [3]. …”