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 $46â¯360â¯176 (P = .94) for participating centers. There was a 77%
fly-out
cost increase postpolicy ($10â¯600â¯234; P = .03). On subanalysis, centers with decreased LT volume postpolicy observed higher overall
hospital costs ($41â¯720â¯365; P = .048), and specifically, a 122%
cost increase for
liver imports ($6â¯508â¯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.