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• W2891031978 abstract "Watch a video presentation of this article Watch the interview with the author Allocation and distribution rules attempt to direct organs to potential transplant recipients who would benefit most from transplantation. Despite changing policies over the last four decades that have struggled to improve organ allocation, as long as donor shortages persist, an equitable system is hard to achieve. Allocation relates to how potential recipients are ordered on a waiting list and since 2002 has been based on the MELD score. Distribution relates to the order in which an organ is offered to different waiting lists and follows a hierarchical system whereby organs are offered at local, regional, or national levels.1 There are currently 11 UNOS regions that are further subdivided into 58 donor service areas (DSAs). Organ procurement organizations (OPOs) are distinct entities charged with organ retrieval and serve each of these DSAs. The Organ Procurement and Transplantation Network (OPTN) was created to enhance the efficiency and equity of organ sharing and is charged with regulation of OPOs and transplant centers. In addition, the Scientific Registry of Transplant Recipients monitors and analyzes transplantation results to identify transplant center strengths and weaknesses that require attention.2 The current division of UNOS regions is arbitrary and based on Medicare's administrative regions for end-stage renal disease.2 It has become apparent that the severity of disease at which a patient receives a liver transplant (LT) as reflected by the MELD score varies across these regions (Fig. 1). When analyzing UNOS data for LTs between 2010 and 2017, we found that median laboratory MELD scores vary significantly according to region, ranging between 22 and 35 at time of LT (Table 1). The percentage of patients transplanted at higher MELD scores also varies significantly across regions. In 1998, the US Department of Health and Human Services proposed the “Final Rule,” a national policy that would codify the process whereby organs from cadaveric donors would be matched to a potential recipient. This was to replace regional policies with a unified system to facilitate enhanced organ sharing across longer distances. A central tenet of this Final Rule is that “neither place of residence nor place of listing shall be a major determinant of access to a transplant.”3 However, since implementation of the Final Rule in 2000, this has not been the case. One study found marked variations in transplantation and death rates while on the waiting list across OPOs and UNOS regions for any particular MELD score (Fig. 2).4 Similarly, another study found a variance of median MELD at time of transplantation of 11.2 across DSAs with clustering of DSAs with high or low median MELD scores in different regions. For example, region 6 contained three DSAs with median MELD scores at transplantation of 22, whereas region 5 contained five DSAs with median MELD scores between 27 and 35.5 These disparities have led to the practice of multiple listings whereby patients in disadvantaged regions seek simultaneous listing in more favorable locations. Cholankeril et al.6 found that patients from region 5 undergoing multiple listing had a higher chance of transplantation (83% versus 36%) at lower MELD scores (25 versus 32) compared with patients listed in region 5 alone. They were more likely to be Caucasian, to have graduate degrees, and to have higher median household incomes.6 Redistricting of the current UNOS regions into optimized evidence-based regions is a potential solution tothese inequalities. Gentry et al.5 hypothesized that broader sharing with optimization of the geographic partitions used would reduce disparities and improve patient outcomes. Existing DSAs were combined into novel optimized regions, which were compared with the current system using the liver simulated allocation model (LSAM). This new model could potentially lead to decreased deaths while on the wait list, decreased variance of MELD at transplantation across regions, and increased allocation of organs to patients with higher MELD scores and to status 1 patients.5 More recently, UNOS published an analysis comparing the current system with an optimized eight-district system using LSAM. The optimized system could potentially lead to decreased MELD variations at transplantation, decreased wait-list and total deaths, and prioritization of patients with higher MELD scores (Table 2).7 Importantly, this model suggests that with modification of the arbitrary lines that divide the current UNOS regions, much of the regional disparity is reduced. This suggests that the existing disparities are to some extent a function of these arbitrary lines. Hirose et al.8 showed that the supply/demand ratio, reflected by the number of eligible deaths per listed patient, varies between 0.10 and 2.86 across DSAs. This variation is expected to decrease under the new system to 0.22 to 0.37. Similarly, Pyke et al.9 demonstrate decreased variation in supply/demand ratios across regions with adoption of the eight-district model (Fig. 3). However, the eight-district system proposed by OPTN has some nuances. With broader sharing, organs may travel longer distances, which may incur increased costs and increased cold ischemia time (CIT), a principal risk factor for graft loss. CIT is associated with graft loss as reflected in the donor risk index.10, 11 However, this association is nonlinear and in one study, increased graft loss was seen only with CIT greater than 10 hours.12 In another study, regional sharing of organs resulted in increased CIT compared with local sharing (7.0 versus 6.0 hours), although remaining below the 10-hour threshold.13 In a single-center study, 3-year survival was similar between recipients of local and regional donors.14 In a financial analysis comparing 5-year Medicare spending under the current system with estimates under the proposed eight-district system, transport costs increased from $269 million to $345 million, although this constituted only 3% of total costs and was offset by decreased pretransplant and posttransplant costs with a net reduction from $8003 million to $7899 million.15 Regional disparities are prevalent and are in violation of the Final Rule as well as the ethical principles of organ allocation. The proposed eight-district system mitigates these disparities in an evidence-based manner through broader sharing and by modifying boundaries that separate areas with low and high supply/demand ratios. This is expected to decrease regional variations of MELD scores at transplantation, decrease wait-list and overall deaths, prioritize patients with higher MELD scores, and decrease overall costs. It is difficult to reach firm conclusions with models that do not account for all the complexities of transplant. However, there are well-established regional disparities that appear to improve when applying an evidence-based regional division as compared with the current arbitrary 11-region system. Monitoring will be critical to evaluate the true impact of the eight-district model and to inform future policy changes that may further improve organ allocation and distribution." @default.
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• W2891031978 title "PRO: Redistricting of United Network for Organ Sharing Regions to Improve Geographic Disparities in Liver Transplantation" @default.
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