Liver Transplant Costs and Activity After United Network for Organ Sharing Allocation Policy Changes,JAMA Surgery

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Liver Transplant Costs and Activity After United Network for Organ Sharing Allocation Policy Changes
JAMA Surgery ( IF 15.7 ) Pub Date : 2024-05-29 , DOI: 10.1001/jamasurg.2024.1208
Ola Ahmed ₁ , Maria Bernadette Majella Doyle ₁ , Marwan S. Abouljoud ₂ , Diane Alonso ₃ , Ramesh Batra ₄ , Kenneth L. Brayman ₅ , Diane Brockmeier ₆ , Robert M. Cannon ₇ , Kenneth Chavin ₈ , Aaron M. Delman ₉ , Derek A. DuBay ₁₀ , Jan Finn ₁₁ , Jonathan A. Fridell ₁₂ , Barry S. Friedman ₁₃ , Danielle M. Fritze ₁₄ , Derek Ginos ₃ , David S. Goldberg ₁₅ , Glenn A. Halff ₁₆ , Seth J. Karp ₁₇ , Vivek K. Kohli ₁₈ , Sean C. Kumer ₁₉ , Alan Langnas ₂₀ , Jayme E. Locke ₇ , Daniel Maluf ₂₁ , Raphael P. H. Meier ₂₁ , Alejandro Mejia ₂₂ , Shaheed Merani ₂₀ , David C. Mulligan ₄ , Bobby Nibuhanupudy ₁₃ , Madhukar S. Patel ₂₃ , Shawn J. Pelletier ₅ , Shimul A. Shah ₉ , Parsia A. Vagefi ₂₃ , Rodrigo Vianna ₂₄ , Gazi B. Zibari ₂₅ , Teresa J. Shafer ₂₆ , Susan L. Orloff ₂₇

Affiliation

Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
Transplant Institute and Hepatobiliary Surgery, Henry Ford Hospital Detroit, Detroit, Michigan
Intermountain Medical Center, Salt Lake City, Utah
Yale New Haven Health Transplantation Center, New Haven, Connecticut
Division of Transplant Surgery, University of Virginia Health System, Charlottesville
Mid-America Transplant Services, St Louis, Missouri
Comprehensive Transplant Institute, University of Alabama, Tuscaloosa
Temple University Health System, Philadelphia, Pennsylvania
Department of Surgery, University Cincinnati Medical Center, Cincinnati, Ohio
Department of Transplant Surgery, Medical University of South Carolina, Charleston
Midwest Transplant Network, Westwood, Kansas
Department of Abdominal Transplant Surgery, Indiana University Health Transplant Institute, Indianapolis
AdventHealth Transplant Institute, Orlando, Florida
Department of Transplant Surgery, University of Texas Health Science Center at San Antonio
Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
University of Texas Health Science Center at San Antonio,
Section of Surgical Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
Department of Transplant and Hepatobiliary Surgery, Integris Baptist Medical Center, Oklahoma City, Oklahoma
Division of Transplantation and Hepatobiliary Surgery, University of Kansas Health System, Kansas City
Division of Transplant Surgery, University of Nebraska Medical Center, Lincoln
Division of Transplantation and Hepatobiliary Surgery, University of Maryland, Baltimore
Methodist Medical Center, Dallas, Texas
Division of Surgical Transplantation, University of Texas Southwestern Medical Center/William P. Clements Jr. University Hospital, Dallas
University of Miami Transplant Institute, Miami, Florida
Willis Knighton Advanced Surgery Center, Willis-Knighton Health System, Shreveport, Louisiana
Teresa Shafer Consulting, Fort Worth, Texas
Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, Oregon Health & Science University, Portland

ImportanceA 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.ObjectiveTo characterize LT volume and cost changes across the US and within specific center groups and demographics after the policy implementation.Design, Setting, and ParticipantsThis 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 MeasuresCenter volume, changes in cost.ResultsA 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 &lt; .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 (&gt;100%) for fly-outs and dry runs in centers from worse-performing health systems.Conclusions and RelevanceBased 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.

更新日期：2024-05-29

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