Geographic Disparity in Liver Transplantation: No Easy Solution

Many in our community have dedicated significant time, research, and thought to the best way to allocate donor organs fairly to patients across the country. However, geographic factors often introduce undesirable anomalies into our organ allocation system. Considering that some regions are net organ exporters while others are net organ importers, it is understandable how contentious battles over a limited resource can arise.

Dr. David Foley and Dr. James Spivey recently represented the AST at an OPTN/UNOS educational forum on increasing equity in access to liver transplantation, and I have invited them to share their take on the forum.

Geographic Disparity in Liver Transplantation: No Easy Solution

David P. Foley, MD, FACS, University of Wisconsin – Chair of the AST’s Liver and Intestinal COP
James R. Spivey, MD, Emory University

At a public forum held in September 2014, the OPTN/UNOS Liver and Intestinal Organ Transplantation Committee presented a proposed redistricting model in which the current 11-region system would be changed to either a 4- or 8-district system with the goal of decreasing geographic disparity1 in liver transplantation. Afterwards, the Liver and Intestine Committee formed multiple ad hoc subcommittees to address the following topics:

  1. alternative metrics of disparity,
  2. financial implications,
  3. logistical and transportation challenges, and
  4. strategies to increase organ donation.

On June 22, 2015, this same OPTN/UNOS committee sponsored an educational forum in Chicago to seek additional public input on concepts that address increasing access to liver transplantation. The two of us attended as AST representatives, along with Libby McDannell, the AST’s Executive Vice President.

At this second forum, the subcommittees reported their recommendations and presented results from comprehensive SRTR analyses using the Liver Simulation Allocation Model (LSAM). Twenty-eight allocation scenarios were analyzed with LSAM, including the current system and broader sharing models involving 11 regions, 8 districts, and 4 districts. Proximity points were also included, whereby a recipient within 150 or 250 miles of the donor hospital would gain additional proximity points in favor of keeping the donor organ local. The LSAM analysis included multiple outcomes that included disparity metrics, summative metrics (wait-list and removal dates prevented, total pre- and post-transplant deaths prevented, and overall waitlist mortality), transport metrics, and cost metrics.

One proposal, presented from the floor by an attendee, suggested including concentric circles around the donor hospital with points given based on proximity without having designated districts. UNOS and the SRTR are now going back to do additional modeling based upon this proposal.

There was good debate over the true benefits of the proposed allocation models. In September, some expressed concern about the appropriateness of using the Model for End-Stage Liver Disease (MELD) score in any capacity as the driver for change. Variation in wait list mortality rates for patients with physiologic MELD scores versus those with the same MELD score granted by exception after presentation to a Regional Review Board create concern in the liver transplant community. However, the June forum seemed to indicate that discussion around a MELD metric would continue.

While changing to either a 4- or 8-district model appears to equalize MELD scores at transplant and organ supply and demand ratios, attendees raised significant thoughts and concerns about the proposed solution:

  • Some suggested that reducing disparity should be based on organ sharing and listing behaviors, rather than on redistricting alone.
  • Because the wait list mortality rates for the same exception and physiologic MELD scores are likely different in higher MELD categories, it was suggested that the proposed system would not lead to treating the sickest patients first.
  • Some suggested that the modeling be redone looking at physiologic MELD scores, as they are the best predictors of wait list mortality. 

 Moving forward, it is clear that more analyses need to be done to formulate the best liver allocation model for reducing geographic disparity. The OPTN/UNOS Liver and Intestinal Committee is addressing the concerns raised from the forum and will report back to the community once all additional analyses are completed.

1Geographic disparity has been defined as the variability in median allocation MELD score at time of transplant.


I thank Dr. Foley and Spivey for their post, well written, though I have some comments. Unlike the view advanced by Dr. Klintmalm (whom I admire greatly), NY is not a region dominated by rich socialites and hedge fund guys. I work in Bronx County, which has a population of over 1.2 million people--larger than many states, with one of the highest rates of organ failure in the U.S. This is largely due to socioeconomic status, access to health care, and a large immigrant population. In our DSA, O blood group patients are transplanted at MELDS of 40. We cannot be confident that even Status 1 fulminants receive offers in time. We manage wait list mortality through weeding out of high risk candidates up front, who we do not think can survive the waiting time, and through live donors and high utilization imported ECD livers (about 30% of volume in NY comes from imports). Resource utilization is high for those recipients lucky enough to be transplanted. Our world is very different from liver practice in Madison or Atlanta, where Dr. Foley and Spivey practice. When possible, NY patients with means choose to travel to places like Atlanta for their transplant, not an option for patients on Medicaid or without supports to travel/relocate. Patients with 3cm solitary HCC's and 22 exception points are told in some of these southern states that they will recieve an offer in "two weeks". In upstate NY, the Rochester region has been drained of patients, travelling over the border to Cleveland, because someone decided decades ago to create a DSA line that separates these two nearby cities. It would be far better for the patients, ultimately, to be able to stay close to their homes and families. Even if our OPO in lower NY performed at the 90th percentile in OPO performance, it would still not resolve the wide geographic disparity. It does not take a lot of sophisticated study to conclude that there is a fundamental issue of fairness in this picture. I came off the UNOS LI committee last cycle, and there was indeed spirited debate but there was consensus that reform was overdue and necessary. The proposals by Segev and Gentry were carefully and thoroughly debated with all regions represented, with an unbiased view towards improving survival for all Americans. While the proposals merit tweaking, Dr. Foley and Spivey's blog post suggest that "more analyses need to be done". I disagree with this assessment. Analyses can be done to address reasonable and realistic concerns, but we should be moving forward rather than bog down in distractions, like discussions about whether wait list mortality is actually higher in small town American versus dense urban counties like the Bronx, or speculation about "listing behavior". I would point out, for transparencies sake, that both Dr. Foley and Dr. Spivey practice in low MELD regions. Interestingly, Wisconsin itself has a micro geographic disparity problem: the denser (and poorer) urban area of Milwaukee is in a different DSA from the more suburban Madison, and has a higher MELD score at transplant. This is partially addressed through Share 35 (which also faced opposition in Madison). I attended a scientific meeting a few years back in which a well known transplant program director from Tennessee publicly argued that the regions like NY which have severe organ gaps should send their patients down to Tennessee for transplantation. The obvious response is that it is far simpler to send the organ from Tennessee up to NY for the patient in greater need, or to send the organ from Madison to Chicago or Milwaukee. The subtext underlying all these discussions by transplant doctors, not generally discussed, is that there is an economic motive to do more transplants. People's livelihoods are at stake after all. The same is true in high MELD or low MELD DSA's. However, as UNOS policy makers and representatives of public health , it's important we keep sight of overall principles of fairness and equity when we have these debates, in order to remain credible with the public. I believe that inaction in this area in the face of such obvious flaws in allocation policy will only promote pathways outside of our control for aggrieved parties, like the courts.

Thanks for your thoughtful and comprehensive comments. Hopefully someone more knowledgeable about livers than I will respond to this post, but Dr. Kinkhabwala does raise some important issues. My first observation is that everyone's opinion is influenced by the perspective from which he or she views the issue. This is human nature, and our tendency to see things from our own vantage point is heightened when lives and livelihoods are both at stake. So how do we make ethical decisions in situations where everyone has a conflict of interest at some level? The modern philosopher and ethicist John Rawls promulgated the concept of the “original position” as a framework for ethical decision making. The original position is a hypothetical state in which the decision maker must act without any knowledge about his or her circumstances or station in life—the so-called “veil of ignorance.” In practical terms, this would mean that our liver allocation system would be designed by someone who did not know if he would become a patient or provider, a recipient or donor, an adult with cirrhosis or a child with biliary atresia, a resident of a high MELD DSA or a low MELD DSA, or a program director from a region with net imports or net exports. However, as optimistic as I am that we will all act in accord from a collective "original position", I think Malthus generally trumps Rawls in the real world-—so look forward to some more arguing. My second observation is that the transplant community has condemned “transplant tourism” abroad for years, yet has remained almost silent on domestic transplant tourism. Should patients with better financial resources be allowed to travel away from their regional center so that they can advantage themselves over someone else? How about being listed at multiple centers or switching your primary waiting time to another center? These examples of “listing gamesmanship” grow naturally out of an imperfect system, but in simplest terms they represent a battle for survival, with the fittest person being the one with the most money and wherewithal. Where is the outrage, people? Seems wrong to me...and I have never been accused of being a bleeding-heart liberal. Have a great weekend. Jim

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