Liver Transplant Costs and Activity After United Network for Organ Sharing Allocation Policy Changes
Recommended Citation
Ahmed O, Doyle MBM, Abouljoud MS, Alonso D, Batra R, Brayman KL, Brockmeier D, Cannon RM, Chavin K, Delman AM, DuBay DA, Finn J, Fridell JA, Friedman BS, Fritze DM, Ginos D, Goldberg DS, Halff GA, Karp SJ, Kohli VK, Kumer SC, Langnas A, Locke JE, Maluf D, Meier RPH, Mejia A, Merani S, Mulligan DC, Nibuhanupudy B, Patel MS, Pelletier SJ, Shah SA, Vagefi PA, Vianna R, Zibari GB, Shafer TJ, and Orloff SL. Liver Transplant Costs and Activity After United Network for Organ Sharing Allocation Policy Changes. JAMA Surg 2024.
Document Type
Article
Publication Date
8-1-2024
Publication Title
JAMA Surg
Abstract
IMPORTANCE: A new liver allocation policy was implemented by United Network for Organ Sharing (UNOS) in February 2020 with the stated intent of improving access to liver transplant (LT). There are growing concerns nationally regarding the implications this new system may have on LT costs, as well as access to a chance for LT, which have not been captured at a multicenter level.
OBJECTIVE: To characterize LT volume and cost changes across the US and within specific center groups and demographics after the policy implementation.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study collected and reviewed LT volume from multiple centers across the US and cost data with attention to 8 specific center demographics. Two separate 12-month eras were compared, before and after the new UNOS allocation policy: March 4, 2019, to March 4, 2020, and March 5, 2020, to March 5, 2021. Data analysis was performed from May to December 2022.
MAIN OUTCOMES AND MEASURES: Center volume, changes in cost.
RESULTS: A total of 22 of 68 centers responded comparing 1948 LTs before the policy change and 1837 LTs postpolicy, resulting in a 6% volume decrease. Transplants using local donations after brain death decreased 54% (P < .001) while imported donations after brain death increased 133% (P = .003). Imported fly-outs and dry runs increased 163% (median, 19; range, 1-75, vs 50, range, 2-91; P = .009) and 33% (median, 3; range, 0-16, vs 7, range, 0-24; P = .02). Overall hospital costs increased 10.9% to a total of $46 360 176 (P = .94) for participating centers. There was a 77% fly-out cost increase postpolicy ($10 600 234; P = .03). On subanalysis, centers with decreased LT volume postpolicy observed higher overall hospital costs ($41 720 365; P = .048), and specifically, a 122% cost increase for liver imports ($6 508 480; P = .002). Transplant centers from low-income states showed a significant increase in hospital (12%) and import (94%) costs. Centers serving populations with larger proportions of racial and ethnic minority candidates and specifically Black candidates significantly increased costs by more than 90% for imported livers, fly-outs, and dry runs despite lower LT volume. Similarly, costs increased significantly (>100%) for fly-outs and dry runs in centers from worse-performing health systems.
CONCLUSIONS AND RELEVANCE: Based on this large multicenter effort and contrary to current assumptions, the new liver distribution system appears to place a disproportionate burden on populations of the current LT community who already experience disparities in health care. The continuous allocation policies being promoted by UNOS could make the situation even worse.
Medical Subject Headings
Liver Transplantation; Humans; Cross-Sectional Studies; United States; Tissue and Organ Procurement; Health Policy; Male; Female; Waiting Lists
PubMed ID
38809546
ePublication
ePub ahead of print
Volume
159
Issue
8
First Page
939
Last Page
947
