Current efforts to revamp the organ allocation system are moving in the wrong direction, according to yesterday’s Thomas E. Starzl lecturer.
Changes currently being discussed by the Organ Procurement and Transplantation Network (OPTN) Liver and Intestinal Transplantation Committee will not bring appreciable improvement to current disparities in organ allocation, said John R. Lake, MD, FAASLD, Professor of Medicine and Executive Medical Director, Solid Organ Transplantation at the University of Minnesota Medical School.
“Geographic disparity in liver transplants is real and it is getting worse,” he said. “The discussion by the OPTN Liver and Intestinal Committee needs to return to what is best for patients rather than what is best for centers.”
Dr. Lake is also senior staff for liver for Scientific Registry of Transplant Recipients (SRTR). He noted that his comments during the Starzl lecture do not reflect the views of either SRTR or the University of Minnesota.
The potential for geographic disparities was recognized early in the history of liver transplantation. The final federal rule that governs allocation by OPTN – 42 CFR Part 121.8(b) – sets a performance goal of reducing the inter-transplant program variance to as small as can be reasonably achieved in any performance indicator as the board determines appropriate.
There are two components to liver allocation, Dr. Lake explained. Group defines the set of candidates available for a particular organ and is based on DSA and region boundaries. Grouping is intended to balance access to transportation and the transportation burden. Ordering defines the sequence in which offers are made to candidates based on candidate and donor characteristics. Ordering is intended to balance illness severity, age, sensitivity and other factors.
Previous policy efforts have focused mostly on ordering, he said, but the OPTN board has more recently focused on grouping. In 2012, the board directed the Liver and Intestine Committee to develop recommendations to reduce what the board called “unacceptably high” geographic disparity in the allocation of organs for transport.
The variance of MELD score at transplant has increased since OPTN implemented a plan to share organs regionally. The committee has devised multiple proposals to create new districts optimized by the numbers of donors and candidates in each DSA and local constraints. Proposals have included four districts, eight districts, 11 districts and more, all with different parameters.
Four district and eight district scenarios showed the greatest improvement in both geographic disparity in transplant and in waitlist mortality rates, Dr. Lake noted, but were abandoned in the face of criticism from transplant centers and other stakeholders. Much of the criticism was misplaced, he said, calling it “fake news.”
Claims that expanding the size of organ distribution units would increase the cost of liver transplantation are patently false, he said. Modeling by SRTR showed that the overall costs of patient care and transport are virtually identical across all scenarios, including the current system. Nor would larger regions bring any significant change in the flow of organs between DSAs or waitlist mortality rates based on type of insurance or rural vs urban location.
“Equity in transplant access relates to the patient, not the center,” Dr. Lake said. “The discussion needs to return to addressing geographic disparities. Current proposals will do nothing to address geographic disparities, which are very real.”