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Ahmed O, Doyle MBM, Abouljoud MS, Alonso D, Batra R, Brayman KL, Brockmeier D, Cannon RM, Chavin K, Delman AM, DuBay DA, Finn J, Fridell JA, Friedman BS, Fritze DM, Ginos D, Goldberg DS, Halff GA, Karp SJ, Kohli VK, Kumer SC, Langnas A, Locke JE, Maluf D, Meier RPH, Mejia A, Merani S, Mulligan DC, Nibuhanupudy B, Patel MS, Pelletier SJ, Shah SA, Vagefi PA, Vianna R, Zibari GB, Shafer TJ, Orloff SL. Liver Transplant Costs and Activity After United Network for Organ Sharing Allocation Policy Changes. JAMA Surg 2024:2819230. [PMID: 38809546 PMCID: PMC11137658 DOI: 10.1001/jamasurg.2024.1208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 02/11/2024] [Indexed: 05/30/2024]
Abstract
Importance A new liver allocation policy was implemented by United Network for Organ Sharing (UNOS) in February 2020 with the stated intent of improving access to liver transplant (LT). There are growing concerns nationally regarding the implications this new system may have on LT costs, as well as access to a chance for LT, which have not been captured at a multicenter level. Objective To characterize LT volume and cost changes across the US and within specific center groups and demographics after the policy implementation. Design, Setting, and Participants This cross-sectional study collected and reviewed LT volume from multiple centers across the US and cost data with attention to 8 specific center demographics. Two separate 12-month eras were compared, before and after the new UNOS allocation policy: March 4, 2019, to March 4, 2020, and March 5, 2020, to March 5, 2021. Data analysis was performed from May to December 2022. Main Outcomes and Measures Center volume, changes in cost. Results A total of 22 of 68 centers responded comparing 1948 LTs before the policy change and 1837 LTs postpolicy, resulting in a 6% volume decrease. Transplants using local donations after brain death decreased 54% (P < .001) while imported donations after brain death increased 133% (P = .003). Imported fly-outs and dry runs increased 163% (median, 19; range, 1-75, vs 50, range, 2-91; P = .009) and 33% (median, 3; range, 0-16, vs 7, range, 0-24; P = .02). Overall hospital costs increased 10.9% to a total of $46 360 176 (P = .94) for participating centers. There was a 77% fly-out cost increase postpolicy ($10 600 234; P = .03). On subanalysis, centers with decreased LT volume postpolicy observed higher overall hospital costs ($41 720 365; P = .048), and specifically, a 122% cost increase for liver imports ($6 508 480; P = .002). Transplant centers from low-income states showed a significant increase in hospital (12%) and import (94%) costs. Centers serving populations with larger proportions of racial and ethnic minority candidates and specifically Black candidates significantly increased costs by more than 90% for imported livers, fly-outs, and dry runs despite lower LT volume. Similarly, costs increased significantly (>100%) for fly-outs and dry runs in centers from worse-performing health systems. Conclusions and Relevance Based on this large multicenter effort and contrary to current assumptions, the new liver distribution system appears to place a disproportionate burden on populations of the current LT community who already experience disparities in health care. The continuous allocation policies being promoted by UNOS could make the situation even worse.
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Affiliation(s)
- Ola Ahmed
- Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Maria Bernadette Majella Doyle
- Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Marwan S. Abouljoud
- Transplant Institute and Hepatobiliary Surgery, Henry Ford Hospital Detroit, Detroit, Michigan
| | - Diane Alonso
- Intermountain Medical Center, Salt Lake City, Utah
| | - Ramesh Batra
- Yale New Haven Health Transplantation Center, New Haven, Connecticut
| | - Kenneth L. Brayman
- Division of Transplant Surgery, University of Virginia Health System, Charlottesville
| | | | - Robert M. Cannon
- Comprehensive Transplant Institute, University of Alabama, Tuscaloosa
| | - Kenneth Chavin
- Temple University Health System, Philadelphia, Pennsylvania
| | - Aaron M. Delman
- Department of Surgery, University Cincinnati Medical Center, Cincinnati, Ohio
| | - Derek A. DuBay
- Department of Transplant Surgery, Medical University of South Carolina, Charleston
| | - Jan Finn
- Midwest Transplant Network, Westwood, Kansas
| | - Jonathan A. Fridell
- Department of Abdominal Transplant Surgery, Indiana University Health Transplant Institute, Indianapolis
| | | | - Danielle M. Fritze
- Department of Transplant Surgery, University of Texas Health Science Center at San Antonio
| | - Derek Ginos
- Intermountain Medical Center, Salt Lake City, Utah
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Glenn A. Halff
- University of Texas Health Science Center at San Antonio
| | - Seth J. Karp
- Section of Surgical Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Vivek K. Kohli
- Department of Transplant and Hepatobiliary Surgery, Integris Baptist Medical Center, Oklahoma City, Oklahoma
| | - Sean C. Kumer
- Division of Transplantation and Hepatobiliary Surgery, University of Kansas Health System, Kansas City
| | - Alan Langnas
- Division of Transplant Surgery, University of Nebraska Medical Center, Lincoln
| | - Jayme E. Locke
- Comprehensive Transplant Institute, University of Alabama, Tuscaloosa
| | - Daniel Maluf
- Division of Transplantation and Hepatobiliary Surgery, University of Maryland, Baltimore
| | - Raphael P. H. Meier
- Division of Transplantation and Hepatobiliary Surgery, University of Maryland, Baltimore
| | | | - Shaheed Merani
- Division of Transplant Surgery, University of Nebraska Medical Center, Lincoln
| | - David C. Mulligan
- Yale New Haven Health Transplantation Center, New Haven, Connecticut
| | | | - Madhukar S. Patel
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center/William P. Clements Jr. University Hospital, Dallas
| | - Shawn J. Pelletier
- Division of Transplant Surgery, University of Virginia Health System, Charlottesville
| | - Shimul A. Shah
- Department of Surgery, University Cincinnati Medical Center, Cincinnati, Ohio
| | - Parsia A. Vagefi
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center/William P. Clements Jr. University Hospital, Dallas
| | - Rodrigo Vianna
- University of Miami Transplant Institute, Miami, Florida
| | - Gazi B. Zibari
- Willis Knighton Advanced Surgery Center, Willis-Knighton Health System, Shreveport, Louisiana
| | | | - Susan L. Orloff
- Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, Oregon Health & Science University, Portland
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Bekki Y, Myers B, Tomiyama K, Imaoka Y, Akabane M, Kwong AJ, Melcher ML, Sasaki K. Decreased Utilization Rate of Grafts for Liver Transplantation After Implementation of Acuity Circle-based Allocation. Transplantation 2024; 108:498-505. [PMID: 37585345 DOI: 10.1097/tp.0000000000004751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
BACKGROUND The allocation system for livers began using acuity circles (AC) in 2020. In this study, we sought to evaluate the impact of AC policy on the utilization rate for liver transplantation (LT). METHODS Using the US national registry data between 2018 and 2022, LTs were equally divided into 2 eras: pre-AC (before February 4, 2020) and post-AC (February 4, 2020, and after). Deceased potential liver donors were defined as deceased donors from whom at least 1 organ was procured. RESULTS The annual number of deceased potential liver donors increased post-AC (from 10 423 to 12 259), approaching equal to that of new waitlist registrations for LT (n = 12 801). Although the discard risk index of liver grafts was comparable between the pre- and post-AC eras, liver utilization rates in donation after brain death (DBD) and donation after circulatory death (DCD) donors were lower post-AC ( P < 0.01; 79.8% versus 83.4% and 23.7% versus 26.0%, respectively). Recipient factors, ie, no recipient located, recipient determined unsuitable, or time constraints, were more likely to be reasons for nonutilization after implementation of the AC allocation system compared to the pre-AC era (20.0% versus 12.3% for DBD donors and 50.1% versus 40.8% for DCD donors). Among non-high-volume centers, centers with lower utilization of marginal DBD donors or DCD donors were more likely to decrease LT volume post-AC. CONCLUSIONS Although the number of deceased potential liver donors has increased, overall liver utilization among deceased donors has decreased in the post-AC era. To maximize the donor pool for LT, future efforts should target specific reasons for liver nonutilization.
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Affiliation(s)
- Yuki Bekki
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Bryan Myers
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Koji Tomiyama
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Yuki Imaoka
- Division of Abdominal Transplant, Department of Surgery, Stanford University, Palo Alto, CA
| | - Miho Akabane
- Division of Abdominal Transplant, Department of Surgery, Stanford University, Palo Alto, CA
| | - Allison J Kwong
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - Marc L Melcher
- Division of Abdominal Transplant, Department of Surgery, Stanford University, Palo Alto, CA
| | - Kazunari Sasaki
- Division of Abdominal Transplant, Department of Surgery, Stanford University, Palo Alto, CA
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Reed RD, Locke JE. Mitigating Health Disparities in Transplantation Requires Equity, Not Equality. Transplantation 2024; 108:100-114. [PMID: 38098158 PMCID: PMC10796154 DOI: 10.1097/tp.0000000000004630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Despite decades of research and evidence-based mitigation strategies, disparities in access to transplantation persist for all organ types and in all stages of the transplant process. Although some strategies have shown promise for alleviating disparities, others have fallen short of the equity goal by providing the same tools and resources to all rather than tailoring the tools and resources to one's circumstances. Innovative solutions that engage all stakeholders are needed to achieve equity regardless of race, sex, age, socioeconomic status, or geography. Mitigation of disparities is paramount to ensure fair and equitable access for those with end-stage disease and to preserve the trust of the public, upon whom we rely for their willingness to donate organs. In this overview, we present a summary of recent literature demonstrating persistent disparities by stage in the transplant process, along with policies and interventions that have been implemented to combat these disparities and hypotheses for why some strategies have been more effective than others. We conclude with future directions that have been proposed by experts in the field and how these suggested strategies may help us finally arrive at equity in transplantation.
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Affiliation(s)
- Rhiannon D. Reed
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E. Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
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Okumura K, Dhand A, Misawa R, Sogawa H, Veillette G, Nishida S. The effects of acuity circle policy on racial disparity in liver transplantation. Surgery 2023; 174:1436-1444. [PMID: 37827898 DOI: 10.1016/j.surg.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 08/03/2023] [Accepted: 09/05/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND A new deceased donor liver allocation policy using an acuity circle-based model was implemented with the goal of providing equitable access to liver transplantation. We assessed the effect of the acuity circle policy on racial disparities in liver transplantation by analyzing waitlist mortality, transplant probability, and post-transplant outcomes. METHODS We conducted a retrospective analysis of 23,717 adult liver transplantation candidates listed during the pre-acuity circle period and 21,051 during the post-acuity circle period (N = 44,768) in the United Network for Organ Sharing database from February 2020 to December 2021. RESULTS Acuity circle-policy implementation was not associated with any significant difference in 90-day waitlist mortality but increased the 90-day probability of all candidates. Implementation did not decrease 90-day waitlist mortality but increased the 90-day transplant probability for all patients. One-year patient and liver graft survival were comparable between the study periods for all recipients, but Black recipients had higher rates of 1-year post-liver transplantation mortality and liver graft failure in both periods. CONCLUSION Although the implementation of the acuity circle policy is associated with an increase in transplant probability in White, Black, and Hispanic liver transplantation candidates, it did not change their waitlist mortality, nor did it lead to any improvement in the preexistent worse post-transplant outcomes in Black liver transplantation recipients.
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Affiliation(s)
- Kenji Okumura
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York. https://twitter.com/KenjiOkumura_MD
| | - Abhay Dhand
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York. https://twitter.com/DhandAbhay
| | - Ryosuke Misawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Hiroshi Sogawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York. https://twitter.com/HiroNewYork
| | - Gregory Veillette
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Seigo Nishida
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York.
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Deshpande R, Shah R, Mulligan DC. New Allocation Systems: Principles and Processes (Pro). Transplantation 2023; 107:2298-2301. [PMID: 37644663 DOI: 10.1097/tp.0000000000004786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Ranjit Deshpande
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT
| | - Rushi Shah
- Department of Anesthesiology, Temple University School of Medicine, Philadelphia, PA
| | - David C Mulligan
- Department of Surgery, Yale University School of Medicine, New Haven, CT
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Giorgakis E, Ivanics T, Wallace D, Wells A, Balogh J, Hardgrave H, Krinock D, Klutts G, Burdine L, Singer A, Mathur A. Acuity circles allocation policy impact on waitlist mortality and donation after circulatory death liver transplantation: A nationwide retrospective analysis. Health Sci Rep 2023; 6:e1066. [PMID: 36751274 PMCID: PMC9892027 DOI: 10.1002/hsr2.1066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/10/2022] [Accepted: 01/06/2023] [Indexed: 02/04/2023] Open
Affiliation(s)
- Emmanouil Giorgakis
- Division of Transplant SurgeryUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Tommy Ivanics
- Multi‐Organ Transplant DepartmentUniversit Health NetworkTorontoCanada
| | - David Wallace
- Institute of Liver StudiesKing's College HospitalLondonUK
| | - Allison Wells
- Division of Transplant SurgeryUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Julius Balogh
- Department of AnesthesiologyUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Hailey Hardgrave
- Department of SurgeryUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Derek Krinock
- Department of SurgeryUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Garrett Klutts
- Department of SurgeryUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Lyle Burdine
- Division of Transplant SurgeryUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Andrew Singer
- Division of Transplant SurgeryMayo ClinicPhoenixArizonaUSA
| | - Amit Mathur
- Division of Transplant SurgeryMayo ClinicPhoenixArizonaUSA
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7
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Wood NL, VanDerwerken DN, Segev DL, Gentry SE. Logistical burden of offers and allocation inefficiency in circle-based liver allocation. Liver Transpl 2023; 29:26-33. [PMID: 35696252 DOI: 10.1002/lt.26527] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/13/2022] [Accepted: 06/08/2022] [Indexed: 01/14/2023]
Abstract
Recent changes to liver allocation replaced donor service areas with circles as the geographic unit of allocation. Circle-based allocation might increase the number of transplantation centers and candidates required to place a liver, thereby increasing the logistical burden of making and responding to offers on organ procurement organizations and transplantation centers. Circle-based allocation might also increase distribution time and cold ischemia time (CIT), particularly in densely populated areas of the country, thereby decreasing allocation efficiency. Using Scientific Registry of Transplant Recipient data from 2019 to 2021, we evaluated the number of transplantation centers and candidates required to place livers in the precircles and postcircles eras, nationally and by donor region. Compared with the precircles era, livers were offered to more candidates (5 vs. 9; p < 0.001) and centers (3 vs. 5; p < 0.001) before being accepted; more centers were involved in the match run by offer number 50 (9 vs. 14; p < 0.001); CIT increased by 0.2 h (5.9 h vs. 6.1 h; p < 0.001); and distribution time increased by 2.0 h (30.6 h vs. 32.6 h; p < 0.001). Increased burden varied geographically by donor region; livers recovered in Region 9 were offered to many more candidates (4 vs. 12; p < 0.001) and centers (3 vs. 8; p < 0.001) before being accepted, resulting in the largest increase in CIT (5.4 h vs. 6.0 h; p < 0.001). Circle-based allocation is associated with increased logistical burdens that are geographically heterogeneous. Continuous distribution systems will have to be carefully designed to avoid exacerbating this problem.
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Affiliation(s)
- Nicholas L Wood
- Department of Mathematics , United States Naval Academy , Annapolis , Maryland , USA
| | | | - Dorry L Segev
- Department of Surgery , Johns Hopkins Hospital , Baltimore , Maryland , USA.,Department of Epidemiology , Johns Hopkins School of Public Health , Baltimore , Maryland , USA
| | - Sommer E Gentry
- Department of Mathematics , United States Naval Academy , Annapolis , Maryland , USA
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Perceptions and Early Outcomes of the Acuity Circles Allocation Policy Among Liver Transplant Centers in the United States. Transplant Direct 2022; 9:e1427. [PMID: 36582673 PMCID: PMC9750633 DOI: 10.1097/txd.0000000000001427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/25/2022] [Accepted: 10/12/2022] [Indexed: 12/27/2022] Open
Abstract
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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Reddy V, da Graca B, Martinez E, Ruiz R, Asrani SK, Testa G, Wall A. Single-center analysis of organ offers and workload for liver and kidney allocation. Am J Transplant 2022; 22:2661-2667. [PMID: 35822324 DOI: 10.1111/ajt.17144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 01/25/2023]
Abstract
The volume of abdominal organ offers received by the Baylor Simmons Transplant Institute has increased over time, resulting in a higher workload for our donor call team. To quantify the increase in organ offers, determine the characteristics of these offers, and estimate the impact on our transplant center workload, we collected center-specific organ offer data from May 2019 to July 2021 using the UNOS Center Acceptance and Refusal Evaluation Report and performed a time study that collected the number of communications and time spent on communications for organ offers made during a typical week. The total offers per month increased by 140% (270/month to 648/month), while the number of transplanted organs remained stable. In addition, the percentage of offers for organs that were never transplanted increased from 54% to 75%. In a representative week-long time study, surgeons made 505, center coordinators 590, and answering service coordinators 318 distinct communications, averaging 3, 4, and 2 communications/hour. Between November 2019 and July 2021, offer-related workload increased by an estimated 97%. These results demonstrate a sizeable inefficiency in abdominal organ allocation associated with a nonrecoverable cost to our transplant center.
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Affiliation(s)
- Vikrant Reddy
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Eric Martinez
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
| | - Richard Ruiz
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
| | - Sumeet K Asrani
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
| | - Giuliano Testa
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
| | - Anji Wall
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
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Burton AM, Goldberg DS. Center-level and region-level variations in liver transplantation practices following acuity circles policy change. Am J Transplant 2022; 22:2668-2674. [PMID: 35758538 DOI: 10.1111/ajt.17131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/19/2022] [Accepted: 06/17/2022] [Indexed: 01/25/2023]
Abstract
Although early studies suggest the Acuity Circles (AC) allocation policy has increased access to deceased donor liver transplants (DDLTs) for patients with the highest MELD scores, changes in center- and region-level practices among patients with the highest MELD scores in response to AC are not well-characterized. OPTN/UNOS data were analyzed to compare center-level changes in the number of DDLTs based on allocation-MELD (aMELD) categories used for AC sharing performed in the 18-month periods before and after AC enactment on February 4, 2020. There was large center-level variation in the number and proportion of aMELD ≥ 37 DDLTs performed from pre-AC to AC period; 13 centers accounted for 196 of the 198 total net increase in aMELD ≥ 37 DDLTs performed after AC, 5 of these being from UNOS region 5. Similar center-level variation was seen for MELD 33-36 and MELD 29-32 DDLTs, with 17 centers and 14 centers, respectively, accounting for the entire net increase in DDLTs in the aMELD categories. In conclusion, AC increased access to livers for transplantation for high MELD patients nationally, but imbalances remain in transplant practice patterns at the center and regional levels. Longer-term study is necessary to assess effectiveness of AC in improving equitability of liver transplantations.
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Affiliation(s)
- Adam M Burton
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David S Goldberg
- Department of Gastroenterology, University of Miami Miller School of Medicine, Miami, Florida, USA
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Kumar SR, Chyou D, Goldberg D. Effect of Acuity Circles Allocation Policy on Local Use of Donation After Circulatory Death Donor Livers. Liver Transpl 2022; 28:1103-1107. [PMID: 35000270 DOI: 10.1002/lt.26402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/01/2021] [Accepted: 12/22/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Smriti Rajita Kumar
- Department of Medicine, Sidney Kimmel College of Medicine/Thomas Jefferson University Hospitals, Philadelphia, PA
| | - Darius Chyou
- University of Miami Miller School of Medicine, Miami, FL
| | - David Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
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12
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Radhakrishnan R, Chyou DE, Goldberg DS. Association of the Liver Acuity Circle Allocation Policy With Timing of Donor Procurements in the US. JAMA Surg 2022; 157:631-633. [PMID: 35583882 DOI: 10.1001/jamasurg.2022.1058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Darius E Chyou
- Miller School of Medicine, University of Miami, Miami, Florida
| | - David Seth Goldberg
- Division of Digestive Health and Liver Disease, Miller School of Medicine, University of Miami, Miami, Florida
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13
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Zendel A, Watkins R, Moon AM, Gerber DA, Iv ASB, Desai CS. Changing opportunities for liver transplant for patients with hepatocellular carcinoma. Clin Transplant 2022; 36:e14609. [PMID: 35137467 DOI: 10.1111/ctr.14609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/20/2022] [Accepted: 01/31/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Aim was to study the early impact of acuity circle-based allocation implementation system, on liver transplantation for hepatocellular carcinoma (HCC) patients. METHODS We assessed characteristics of HCC and non-HCC deceased donor orthotopic liver transplants (OLT) in the year before (2/2019-2/2020) and after (3/2020-2/2021) introduction of the acuity circle policy using the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) database. RESULTS Total OLTs reduced from 6699 in the pre-acuity circle era to 6660 in the post-acuity circle era (-0.6%); this decrease is mostly driven by a decrease in HCC transplants (1529 to 1351; -11.6%). Six out of 11 regions had a reduction in the absolute number and percentage of HCC transplants with significant reductions in regions 2 (-37.8%, p<0.001) and 4 (-28.3%, p = 0.001). DISCUSSION The introduction of median model for end-stage liver disease (MELD) at transplant minus 3 (MMaT-3) exception points, has created differential opportunities for HCC patients, in low-MELD as opposed to high-MELD areas, despite having the same disease. This effect has become more prominent following the implementation of acuity circle-based allocation system. Ongoing investigation of these trends is needed to ensure that HCC patients are not disparately disadvantaged due to their location. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alex Zendel
- Division of Abdominal Transplant Surgery, Department of Surgery, University of North Carlina at Chapel Hill School of Medicine, Chapel hill, NC, USA
| | - Randall Watkins
- Division of Abdominal Transplant Surgery, Department of Surgery, University of North Carlina at Chapel Hill School of Medicine, Chapel hill, NC, USA
| | - Andrew M Moon
- Division of GI Medicine, Department of Medicine, University of North Carlina at Chapel Hill School of Medicine, Chapel hill, NC, USA
| | - David A Gerber
- Division of Abdominal Transplant Surgery, Department of Surgery, University of North Carlina at Chapel Hill School of Medicine, Chapel hill, NC, USA
| | - A Sidney Barritt Iv
- Division of GI Medicine, Department of Medicine, University of North Carlina at Chapel Hill School of Medicine, Chapel hill, NC, USA
| | - Chirag S Desai
- Division of Abdominal Transplant Surgery, Department of Surgery, University of North Carlina at Chapel Hill School of Medicine, Chapel hill, NC, USA
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Ivanics T, Vianna R, Kubal CA, Iyer KR, Mazariegos GV, Matsumoto CS, Mangus R, Beduschi T, Abouljoud M, Fridell JA, Nagai S. Impact of the acuity circle model for liver allocation on multivisceral transplant candidates. Am J Transplant 2022; 22:464-473. [PMID: 34403552 DOI: 10.1111/ajt.16803] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/22/2021] [Accepted: 08/11/2021] [Indexed: 01/25/2023]
Abstract
Liver allocation was updated on February 4, 2020, replacing a Donor Service Area (DSA) with acuity circles (AC). The impact on waitlist outcomes for patients listed for combined liver-intestine transplantation (multivisceral transplantation [MVT]) remains unknown. The Organ Procurement and Transplantation Network/United Network for Organ Sharing database was used to identify all candidates listed for both liver and intestine between January 1, 2018 and March 5, 2021. Two eras were defined: pre-AC (2018-2020) and post-AC (2020-2021). Outcomes included 90-day waitlist mortality and transplant probability. A total of 127 adult and 104 pediatric MVT listings were identified. In adults, the 90-day waitlist mortality was not statistically significantly different, but transplant probability was lower post-AC. After risk-adjustment, post-AC was associated with a higher albeit not statistically significantly different mortality hazard (sub-distribution hazard ratio[sHR]: 8.45, 95% CI: 0.96-74.05; p = .054), but a significantly lower transplant probability (sHR: 0.33, 95% CI: 0.15-0.75; p = .008). For pediatric patients, waitlist mortality and transplant probability were similar between eras. The proportion of patients who underwent transplant with exception points was lower post-AC both in adult (44% to 9%; p = .04) and pediatric recipients (65% to 15%; p = .002). A lower transplant probability observed in adults listed for MVT may ultimately result in increased waitlist mortality. Efforts should be taken to ensure equitable organ allocation in this vulnerable patient population.
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Affiliation(s)
- Tommy Ivanics
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Michigan, USA.,Department of Surgical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden
| | - Rodrigo Vianna
- Division of Liver/GI Transplant, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, Florida, USA
| | - Chandrashekhar A Kubal
- Division of Abdominal Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kishore R Iyer
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cal S Matsumoto
- Medstar Georgetown University Hospital, Medstar Georgetown Transplant Institute, Washington, DC, USA
| | - Richard Mangus
- Division of Abdominal Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Thiago Beduschi
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Michigan, USA
| | - Jonathan A Fridell
- Division of Abdominal Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Michigan, USA
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15
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Wall AE, da Graca B, Asrani SK, Ruiz R, Fernandez H, Gupta A, Martinez E, Bayer J, McKenna GJ, Goldstein R, Onaca N, Trotter JF, Testa G. Cost Analysis of Liver Acquisition Fees Before and After Acuity Circle Policy Implementation. JAMA Surg 2021; 156:1051-1057. [PMID: 34495291 DOI: 10.1001/jamasurg.2021.4406] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Acuity circles (AC) liver allocation policy was implemented to eliminate donor service area geographic boundaries from liver allocation and to decrease variability in median Model of End-stage Liver Disease (MELD) score at transplant and wait list mortality. However, the broader sharing of organs was also associated with more flights for organ procurements and higher costs associated with the increase in flights. Objective To determine whether the costs associated with liver acquisition changed after the implementation of AC allocation. Design, Setting, and Participants This single-center cost comparison study analyzed fees associated with organ acquisition before and after AC allocation implementation. The cost data were collected from a single transplant institute with 2 liver transplant centers, located 30 miles apart, in different donation service areas. Cost, recipient, and transportation data for all cases that included fees associated with liver acquisition from July 1, 2019, to October 31, 2020, were collected. Exposures Primary liver offer acceptance with associated organ procurement organization or charter flight fees. Main Outcomes and Measures Specific fees (organ acquisition, surgeon, import, and charter flight fees) and total fees per donor were collected for all accepted liver donors with at least 1 associated fee during the study period. Results Of 213 included donors, 171 were used for transplant; 90 of 171 (52.6%) were male, and the median (interquartile range) age of donors was 41.0 (30.0-52.8) years in the pre-AC period and 36.9 (24.0-48.8) years in the post-AC period. There was no significant difference in the post-AC compared with pre-AC period in median (range) MELD score (24 [8-40] vs 25 [6-40]; P = .27) or median (range) match run sequence (15 [1-3951] vs 10 [1-1138]; P = .31), nor in mean (SD) distance traveled (155.83 [157.00] vs 140.54 [144.33] nautical miles; P = .32) or percentage of donors requiring flights (58.5% [69 of 118] vs 56.8% [54 of 95]; P = .82). However, costs increased significantly in the post-AC period: total cost increased 16% per accepted donor (mean [SD] of $52 966 [13 278] vs $45 725 [9300]; P < .001) and 55% per declined donor (mean [SD] of $15 865 [3942] vs $10 217 [4853]; P < .001). Contributing factors included more than 2-fold increases in the proportions of donors incurring import fees (31.4% [37 of 118] vs 12.6% [12 of 95]; P = .002) and surgeon fees (19.5% [23 of 118] vs 9.5% [9 of 95]; P = .05), increased acquisition fees (10% increase; mean [SD] of $43 860 [3266] vs $39 980 [2236]; P < .001), and increased flight expenses (43% increase; mean [SD] of $12 904 [6066] vs $9049 [5140]; P = .002). Conclusions and Relevance The unintended consequences of implementing broader sharing without addressing organ acquisition fees to account for increased importation between organ procurement organizations must be remedied to contain costs and ensure viability of transplant programs.
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Affiliation(s)
- Anji E Wall
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Briget da Graca
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas
| | - Sumeet K Asrani
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Richard Ruiz
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Hoylan Fernandez
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Amar Gupta
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Eric Martinez
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Johanna Bayer
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Gregory J McKenna
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Robert Goldstein
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Nicholas Onaca
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - James F Trotter
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Giuliano Testa
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
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