AST Board of Directors Response to Liver Allocation Public Comment

Dear Colleagues,

As you are aware, there has been considerable controversy around the topic of liver allocation. The recent developments requiring the UNOS Board to adopt a new liver allocation policy by December, that does not use the donor service area (DSA) as the unit of organ distribution, has furthered discussion on this important issue. The AST Board would like to take this opportunity to describe the process that the AST uses to respond to public comment and strongly encourages your participation in this important process.

The AST Board’s response to the request for public comment by UNOS on the proposed changes to the liver allocation policy has already been posted. The proposed policy changes were advanced in response to a directive from the HHS Secretary to eliminate DSA boundaries in liver allocation because of a lawsuit challenging DSA as a unit of allocation.

Specifically 121.8(8) states:

“Shall not be based on the candidate's place of residence or place of listing, except to the extent required by paragraphs (a)(1)-(5) of this section.”

The Final Rule requires that organ allocation policies be based on sound medical judgment, that policies make the best use of organs, allow transplant hospitals to decide whether to accept an organ offer, avoid wasting organs, and promote efficiency. As referenced above, the Final Rule includes a requirement that policies “shall not be based on the candidate’s place of residence or place of listing, except to the extent required” by the other requirements of the Final Rule. This is the current issue in question, as current policies use donation service areas (DSAs) and OPTN regions as geographic units.

The AST Board recognizes that there have been long-standing efforts to advance policies to mitigate the complex issue of geographic disparities in access to liver transplantation. The Board understands that given the realities of the organ shortage, and the unique challenges within different regions of the country, any single proposal is unlikely to be met with the approval of all our members. The Board understands that the UNOS proposal, advanced on a short timeline in response to a directive for the HHS Secretary, is not the final chapter in our collective efforts to minimize geographic disparities in access to liver transplantation. The AST remains committed to working with our community to find optimal solutions.

As part of this commitment, the Board believed that it was important to respond to the specific questions posed in UNOS request for comment and not issue a generic statement. The AST response was based on our process of broad engagement through our Communities of Practice and the expertise contained within. AST members were provided an opportunity to share their opinions and concerns about the UNOS proposal, and we are grateful to our members who gave their time to participate in this process. We believe the response reflects the consensus opinion of our members who contributed to this effort. However, we realize that we may not have heard from everyone who wanted to share their thoughts and we continue to welcome and encourage additional input from our members on this important issue. The overall goal remains to develop the most equitable policies.

Members should be assured that the AST’s vote on the UNOS Policy in December 2018 will be informed by all of the input we receive from our members and any changes to the current AST position will be fully communicated to our members.

We strongly encourage all interested members to participate in this important discussion as well as any future discussions related to UNOS policy proposals. We welcome comments from our members as we move forward so that our vote in December reflects the opinions of our community.