Organ Allocation Rule Change Has Liver Recovery Teams Traveling Twice as Far

(Reuters Health) – The February 2020 change in how organs are allocated for transplant has resulted in recovery teams traveling twice as far to collect livers, and also in more livers both leaving and brought into regions other than where they were collected, a U.S. study suggests.

The new policy, implemented by the Organ Procurement Transplant Network and the United Network for Organ Sharing (UNOS), moved away from a donor service-area-based allocation model to a radial-distance-based one in order to improve access to transplant for the candidates with the greatest urgency, reduce waitlist mortality, and increase pediatric transplants, the authors note in JAMA Surgery.

“What we’ve seen in our limited time frame is a significant increase in travel related to the new allocation policy,” said the study’s lead author, Dr. Kyle Sheets, chief resident in general surgery at the University of Michigan, Ann Arbor. “We need to keep a close eye on that as we balance it against whether the new policy achieves its stated outcomes.”

The problem the policy change is meant to address is that in some regions patients would become sicker before getting a transplant than in other regions. “More specifically, Dr. Sheetz said, “an organ could become available in Toledo, Ohio, and we wouldn’t get it in Ann Arbor, which is just an hour away,” because Ann Arbor and Toledo are in two different regions.

The result in that scenario was that a less-sick patient in Toledo would have first dibs on the liver, while a sicker patient in Ann Arbor would have to wait for another one.

The new policy would avoid that inequity by giving the organ to the sickest patient who is closest to the donor, regardless of region.

To take a closer look at the impact of the policy change on the distance recovery teams needed to travel, the researchers turned to data from UNOS between January 3 and March 3, 2020. The March 3 cutoff was chosen because it was before dramatic COVID-19-related changes in practice.

The researchers collected data on liver donations after brain death versus circulatory death, location of donor and recipient hospitals, and the UNOS regions of both the donor and recipient. The primary outcome investigated was the distance between the donor and recipient hospitals, which functioned as a surrogate for organ recovery travel distance, measured as the straight-line distance between donor and recipient hospitals based on longitude and latitude coordinates.

The researchers also measured the proportion of recovered livers that were imported and exported by each UNOS region.

Overall, implementation of the new policy was associated with a 105% relative increase in travel by recovery teams, from 130.4 km to 267.2 km. Some regions saw a larger relative increase in travel distance, such as region eight in the central U.S., where travel increased by 381%, from 77.2 km to 370.1 km. Others, such as region four (Oklahoma and Texas), saw little change, going from 251.1 km to 249.4 km (−0.1%).

The policy was also associated with changes in the number of organs imported and exported by UNOS regions. After implementation, transplant centers imported 309.8% more livers (61 before and 250 after implementation) from outside of their regions. Regions also exported 344% more livers (54 before implementation and 240 after implementation) to another region. During the same period, the number of transplants stayed relatively stable (797 versus 779), as did available donors (790 versus 769).

The concern related to these changes is that the extra travel will expose recovery teams to greater danger from potential accidents, Sheetz said.

The policy changes arose out of a directive from the Health Resources and Services Administration to lessen the impact of geography, said Dr. George Mazariegos, division chief of pediatric transplantation at UPMC Children’s Hospital of Pittsburgh.

What was happening, Dr. Mazariegos said, is in some regions a person might have a higher medical end stage liver disease (MELD) score before getting a transplant than someone in another region. “High population centers, such as the East Coast, that also had high patient populations typically had a higher MELD requirement for transplant than regions such as 11, which had fewer candidates and potentially more donors,” said Dr. Mazariegos, who was not involved with the new research.

While “the impact of distance could lead to increased costs along with safety concerns, the goal of the overall policy was to reduce variation across the country,” Dr. Mazariegos said. “And most of the United States has been able to get similar MELD scores, and that was the objective.”

Still, Dr. Mazariegos said, there needs to be ongoing monitoring to make sure that the policy doesn’t have a negative effect on rural or economically disadvantaged populations.

SOURCE: https://bit.ly/3cHrjum JAMA Surgery, online March 17, 2021.

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