Data reflect the median distance traveled by livers transplanted by centers within each region. The distance reflects that linear distance between the donor and recipient hospitals. The percentages describe the relative change in median travel for the months immediately before and after implementation of acuity circles on February 4, 2020. Statistics are not adjusted for center-level or region-level the median models for end-stage liver disease at transplant.
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Sheetz KH, Waits SA. Outcome of a Change in Allocation of Livers for Transplant in the United States. JAMA Surg. 2021;156(5):496–498. doi:10.1001/jamasurg.2021.0137
On February 4, 2020, the Organ Procurement and Transplant Network and United Network for Organ Sharing (UNOS) implemented a new policy for allocating donor livers for transplant. The policy moves away from a donor service area–based allocation model and instead focuses on radially oriented zones (acuity circles) around potential donors. Its goals are to improve access to transplant for the candidates with the greatest urgency, increase the number of pediatric transplants, and reduce waitlist mortality.1 However, there are also concerns that it may reduce access for socioeconomically disadvantaged groups (eg, patients in rural areas) and significantly increase travel burden for liver recovery.2-4 Using data from UNOS, we assessed whether implementation of the policy was associated with immediate changes in the distance traveled for recovery or the proportion of organ imports or exports by UNOS regions.
We identified all accepted liver offers from deceased donors between January 3 and March 3, 2020 (prior to dramatic changes in practice because of the coronavirus disease 2019 pandemic). We collected data regarding donation after brain vs circulatory death, location of the donor and recipient hospitals, and the UNOS regions of both the donor and recipient. Our primary outcomes were the distance between the donor and recipient hospitals 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. We also measured the proportion of recovered livers that were imported and exported by each UNOS region. This study was deemed exempt by the institutional review board of the University of Michigan. We calculated the raw unadjusted differences and relative change in each outcome before and after implementation of the policy on February 4, 2020. All analyses and geographic mapping were performed in Stata version 15 (StataCorp).
The Figure shows changes in the estimated median distance traveled to recover accepted livers for transplant. Implementation of the acuity circle policy was associated with a 105% relative increase in travel by recovery teams (130.4 to 267.2 km) across the country. While some regions, such as region 8, saw larger relative increases in travel distance (381% [77.2 to 370.1 km]), others, such as region 4, experienced little difference (−0.1% [251.1 to 249.4 km]).
The policy was also associated with changes in the number of organs imported and exported by UNOS regions (Table). For example, after implementation, transplant centers imported 309.8% more livers (61 before and 250 after implementation) from outside of their region. Regions also exported 344% more livers (54 before implementation and 240 after implementation) recovered to another region. At the same time, the number of transplants (797 vs 779 [−2.3%]) and available donors (790 vs 769 [−2.7%]) remained qualitatively stable.
The median travel distance to recover a liver more than doubled in the month after the acuity circle policy was implemented. While some UNOS regions saw relatively little change in travel, others experienced a nearly 400% increase in the month following implementation. The policy was also associated with a greater proportion of livers being imported and exported from UNOS regions.
This study is limited by its short time frame, and it is too soon to determine whether the increase in travel distance will continue or ultimately limit the policy from reaching its intended goals. We are also unable to determine how this may affect known variation in the median model for end-stage liver disease at transplant in the long term. More travel could affect the policy’s aims if, for example, it leads to higher organ acquisition costs for transplant centers, which in turn affect access for patients who are uninsured or underinsured. These findings nonetheless require ongoing evaluation to establish whether they are a transient consequence of the policy change or a permanent feature of organ recovery under the new policy.
Finally, any change in liver allocation reminds the transplant community that cooperation between transplant centers, organ procurement organizations, and policy makers is key. It can foster innovative changes in organ recovery practices, such as local recovery, that may be necessary should centers continue to experience increasing travel demands under the new policy.
Accepted for Publication: January 2, 2021.
Published Online: March 17, 2021. doi:10.1001/jamasurg.2021.0137
Corresponding Author: Kyle H. Sheetz, MD, MSc, Center for Healthcare Outcomes and Policy, 2800 Plymouth Rd, NCRC B016, Room 100N-11, Ann Arbor, MI 48109 (firstname.lastname@example.org).
Author Contributions: Drs Sheetz and Waits had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Sheetz.
Conflict of Interest Disclosures: None reported.