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Policy changes governing liver transplant allocation in the United States were intended to increase the number of transplants and make the process more equitable, but new research raises concerns that certain underserved communities may end up at a greater disadvantage.
The new liver allocation policy changed the geographical criteria for organ recipients. Instead of operating within a defined regional service area, the new policy prioritizes the sickest liver candidates registered with transplant hospitals within a 500 nautical mile radius of the donor hospital. The policy was implemented in February 2020 by the Organ Sharing Network, which is contracted by the federal Organ Procurement and Transplantation Network.
in study In a paper published Wednesday in the medical journal JAMA Surgery, researchers evaluated outcomes during the first year under the new policy at 22 transplant centers that account for about a quarter of the nation's transplants. They found that the cost of liver transplants was about 11% higher than the previous year, mainly due to the costs associated with increased air freight to transport donor livers.
In this sample of transplant centers, which was not identified in the study, the total number of liver transplants decreased by 6 percent, and changes in transplant and donor volumes suggest an increased discard rate, the study said.
“Despite fewer patients receiving transplants since the policy was implemented, transplant centers in lower-income states, centers serving areas with higher numbers of racial and ethnic minorities, and centers in states with weaker health care systems faced higher costs,” the study authors wrote.
Geographic disparities have long been a challenge facing transplant systems, and the issue is particularly acute in the case of liver transplants, as livers do not survive as long from donor to transplant as other organs.
While rural areas are at a widespread disadvantage when it comes to organ transplants, this study suggests that the new liver allocation policy may create an even more disproportionate burden: The researchers found that rural centers experienced a larger decrease in the number of liver transplants, an increase in imported livers, and a larger increase in hospitalization and airfare costs.
For the University of Arkansas for Medical Sciences, the new 500-nautical-mile radius could mean staff traveling to Chicago, Houston or Nashville to obtain a donor liver and bring it back to a transplant patient in Little Rock.
“It's costly, but if this is in the best interest of the recipient, time will tell, but we just want to do the right thing to honor the organ donation from the donor,” said Dr. Lyle Burdin, director of the medical center's solid organ transplant program.
The center has prepared for changes in liver transplant policy by adding staff to ease the growing logistical burden and developing programs to preserve organs longer during the transition period between donor and transplant patient.
“What we couldn't do then, and what no transplant center has been able to do, is change the hospital's payer reimbursement rates for these increased costs, which probably remain at the late 1990s,” Burdine says, “and the financial pressures of care are really being felt at the fringes.”
A related editorial, also published Wednesday in JAMA Surgery, suggests that broader, longer-term analysis is important before determining how the new policy is working.
While it is clear that not all transplant centers are “equally flexible to changes in national allocation policies,” the sample of centers used in the new analysis may not be nationally representative, wrote the authors, led by Daniella Ladner, PhD, founding director of the Transplant Outcomes Research Consortium at Northwestern University. According to federal data, liver transplants have increased across the U.S., despite declines seen in the sample of 22 centers.
The new policy was implemented during the peak of the COVID-19 pandemic, potentially skewing the results and findings. Also, “the field is changing rapidly,” especially with the advent of new technologies such as normothermic perfusion pumps that allow donor livers to travel longer distances, the researchers wrote.
At the University of Kansas Medical Center, under the new allocation policy, the number of liver transplants fell by about 40 percent in the first two years, the cost per transplant increased by about 15 percent and the number of livers from local donors fell from about 90 percent to about 15 percent, said Dr. Timothy Schmidt, the system's transplant chief.
Some of these changes were expected based on models that projected how the new policy would play out, he said, but they also created a situation in which people receiving liver transplants ended up significantly sicker than they would have been under the old policy.
“That's made a big difference in our practice,” Schmidt says. Now, some people who would have been considered eligible for a liver transplant may not be placed on the waiting list because they wouldn't survive the wait. “It makes it harder to have those tough conversations because people are going to be waiting longer.”
However, the Unified Network for Organ Donation National achievements A year has passed under the new policy and the results are promising.
“We will consider local impacts and center impacts, but most importantly we will focus on patients and what is going on nationally,” said Dr. Scott Biggins, chairman of the federal government's liver transplant committee. “This policy has reduced waitlist mortality, increased access to liver transplants nationwide, and had little adverse effect on post-transplant outcomes in terms of post-transplant survival.”
It has been four years since the latest liver transplant policy was implemented, and the committee has also begun work on further updating the policy to make the allocation process “continuous” rather than “categorical,” Biggins said.
Currently, liver allocation is primarily aimed at getting livers to the sickest patients soonest, based on each patient's score from an end-stage liver disease model, but the new model will also focus on improving the efficiency of the system rather than relying solely on urgency, he said.
The update could alleviate some of the concerns Schmidt has, as he would appreciate a more “matrix-type allocation scheme” that would allow flexibility to factor in travel costs in some way.
Projections of potential updates to the transplant policy are still under review and could take years to be finalized after consultation with the public and other stakeholders.
“There's a lot of opportunity going forward to focus on patients rather than profits,” Biggins said. “Healthcare is a business, but our focus is improving the lives and health of patients, and the best way to get organs to people who need them should be our North Star here.”
