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Mankowski MA, Wood NL, Massie AB, Segev DL, Trichakis N, Gentry SE. Targeted Broader Sharing for Liver Continuous Distribution. Transplantation 2024:00007890-990000000-00865. [PMID: 39245819 DOI: 10.1097/tp.0000000000005184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
BACKGROUND In recent years, changes to US organ allocation have aimed to improve equity and accessibility across regions. The Organ Procurement and Transplantation Network plans to adopt continuous liver distribution, prioritizing candidates based on a weighted composite allocation score (CAS) incorporating proximity, ABO types, medical urgency, and pediatric priority. The Liver Committee has requested research on CAS variations that account for geographical heterogenicity. METHODS We describe a method for designing a geographically heterogeneous CAS with targeted broader sharing (CAS-TBS) to balance the highly variable geographic distributions of liver transplant listings and liver donations. CAS-TBS assigns each donor hospital to either broader sharing or nearby sharing, adjusting donor-candidate distance allocation points accordingly. RESULTS We found that to reduce geographic disparity in the median Model for End-stage Liver Disease at transplant (MMaT), >75% of livers recovered in regions 2 and 10 should be distributed with broader sharing, whereas 95% of livers recovered in regions 5 and 1 should be distributed with nearby sharing. In a 3-y simulation of liver allocation, CAS-TBS decreased MMaT by 2.1 points in high-MMaT areas such as region 5 while increasing MMaT only by 0.65 points in low-MMaT areas such as region 3. CAS-TBS significantly decreased median transport distance from 202 to 167 nautical miles under acuity circles and decreased waitlist deaths. CONCLUSIONS Our CAS-TBS design methodology could be applied to design geographically heterogeneous allocation scores that reflect transplant community values and priorities within the continuous distribution project of the Organ Procurement and Transplantation Network. In our simulations, the incremental benefit of CAS-TBS over CAS was modest.
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Affiliation(s)
- Michal A Mankowski
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Nicholas L Wood
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Allan B Massie
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Dorry L Segev
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Nikolaos Trichakis
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA
| | - Sommer E Gentry
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
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Ishaque T, Beckett J, Gentry S, Garonzik-Wang J, Karhadkar S, Lonze BE, Halazun KJ, Segev D, Massie AB. Waitlist Outcomes for Exception and Non-exception Liver Transplant Candidates in the United States Following Implementation of the Median MELD at Transplant (MMaT)/250-mile Policy. Transplantation 2024; 108:e170-e180. [PMID: 38548691 DOI: 10.1097/tp.0000000000004957] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
BACKGROUND Since February 2020, exception points have been allocated equivalent to the median model for end-stage liver disease at transplant within 250 nautical miles of the transplant center (MMaT/250). We compared transplant rate and waitlist mortality for hepatocellular carcinoma (HCC) exception, non-HCC exception, and non-exception candidates to determine whether MMaT/250 advantages (or disadvantages) exception candidates. METHODS Using Scientific Registry of Transplant Recipients data, we identified 23 686 adult, first-time, active, deceased donor liver transplant (DDLT) candidates between February 4, 2020, and February 3, 2022. We compared DDLT rates using Cox regression, and waitlist mortality/dropout using competing risks regression in non-exception versus HCC versus non-HCC candidates. RESULTS Within 24 mo of study entry, 58.4% of non-exception candidates received DDLT, compared with 57.8% for HCC candidates and 70.5% for non-HCC candidates. After adjustment, HCC candidates had 27% lower DDLT rate (adjusted hazard ratio = 0.68 0.73 0.77 ) compared with non-exception candidates. However, waitlist mortality for HCC was comparable to non-exception candidates (adjusted subhazard ratio [asHR] = 0.93 1.03 1.15 ). Non-HCC candidates with pulmonary complications of cirrhosis or cholangiocarcinoma had substantially higher risk of waitlist mortality compared with non-exception candidates (asHR = 1.27 1.70 2.29 for pulmonary complications of cirrhosis, 1.35 2.04 3.07 for cholangiocarcinoma). The same was not true of non-HCC candidates with exceptions for other reasons (asHR = 0.54 0.88 1.44 ). CONCLUSIONS Under MMaT/250, HCC, and non-exception candidates have comparable risks of dying before receiving liver transplant, despite lower transplant rates for HCC. However, non-HCC candidates with pulmonary complications of cirrhosis or cholangiocarcinoma have substantially higher risk of dying before receiving liver transplant; these candidates may merit increased allocation priority.
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Affiliation(s)
- Tanveen Ishaque
- Department of Surgery, New York University Langone Transplant Institute, New York, NY
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - James Beckett
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sommer Gentry
- Department of Surgery, New York University Langone Transplant Institute, New York, NY
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
- Scientific Registry of Transplant Recipients, Minneapolis, MN
| | - Jacqueline Garonzik-Wang
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sunil Karhadkar
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Bonnie E Lonze
- Department of Surgery, New York University Langone Transplant Institute, New York, NY
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Karim J Halazun
- Department of Surgery, New York University Langone Transplant Institute, New York, NY
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Dorry Segev
- Department of Surgery, New York University Langone Transplant Institute, New York, NY
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
- Scientific Registry of Transplant Recipients, Minneapolis, MN
| | - Allan B Massie
- Department of Surgery, New York University Langone Transplant Institute, New York, NY
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
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Tanaka T, Ross-Driscoll K, Pancholia S, Axelrod D. Body Size Remains the Major Source of Sex Disparity Despite Updated Liver Transplant Allocation Policies. Transplantation 2024:00007890-990000000-00818. [PMID: 39020468 DOI: 10.1097/tp.0000000000005142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
BACKGROUND Efforts to address US liver transplant (LT) access inequities continue, yet disparities linked to candidate traits persist. METHODS Analyzing national registry data pre- and post-Acuity Circle (AC) policy, our study assessed the impact of low body surface area (BSA) on LT waitlist mortality. The outcomes of LT candidates listed in the pre-AC era (n = 39 227) and post-AC (n = 38 443) were compared for patients with low BSA (22.9% pre-AC and 23.3% post-AC). RESULTS Fine-Gray competing risk models highlighted that candidates with low BSA had a lower likelihood of LT both pre-AC (hazard ratio [HR] 0.93; 95% confidence interval [CI], 0.92-0.95) and post-AC (HR 0.96; 95% CI, 0.94-0.98), with minimal improvement in waitlist mortality/dropout risk from pre-AC (HR 1.15; 95% CI, 1.09-1.21) to post-AC (HR 1.13; 95% CI, 1.06-1.19). Findings were mostly reaffirmed by Cox regression models incorporating the trajectory of Model for End-stage Liver Disease (MELD) scores as time-dependent covariates. Regions 3, 5, and 7 showed notable LT waitlist disparities among low BSA patients post-AC policy. Causal mediation analysis revealed that low BSA and the difference between MELD-sodium and MELD 3.0 (MELD_D, as a proxy for the potential impact of the introduction of MELD 3.0) largely explained the sex disparity in AC allocation (percent mediated 90.4). CONCLUSIONS LT waitlist disparities for female candidates persist, largely mediated by small body size. Although MELD 3.0 may reduce some disparities, further body size adjustments for in allocation models are justified.
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Affiliation(s)
- Tomohiro Tanaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA
| | - Katherine Ross-Driscoll
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN
| | - Smita Pancholia
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - David Axelrod
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
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Reed RD, Locke JE. Mitigating Health Disparities in Transplantation Requires Equity, Not Equality. Transplantation 2024; 108:100-114. [PMID: 38098158 PMCID: PMC10796154 DOI: 10.1097/tp.0000000000004630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Despite decades of research and evidence-based mitigation strategies, disparities in access to transplantation persist for all organ types and in all stages of the transplant process. Although some strategies have shown promise for alleviating disparities, others have fallen short of the equity goal by providing the same tools and resources to all rather than tailoring the tools and resources to one's circumstances. Innovative solutions that engage all stakeholders are needed to achieve equity regardless of race, sex, age, socioeconomic status, or geography. Mitigation of disparities is paramount to ensure fair and equitable access for those with end-stage disease and to preserve the trust of the public, upon whom we rely for their willingness to donate organs. In this overview, we present a summary of recent literature demonstrating persistent disparities by stage in the transplant process, along with policies and interventions that have been implemented to combat these disparities and hypotheses for why some strategies have been more effective than others. We conclude with future directions that have been proposed by experts in the field and how these suggested strategies may help us finally arrive at equity in transplantation.
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Affiliation(s)
- Rhiannon D. Reed
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E. Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
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5
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Nagai S, Ivanics T, Kitajima T, Shimada S, Shamaa TM, Collins K, Rizzari M, Yoshida A, Moonka D, Abouljoud M. Disparities in the Effects of Acuity Circle-based Liver Allocation on Waitlist and Transplant Practice Between Centers. Transplant Direct 2022; 8:e1356. [PMID: 36176726 PMCID: PMC9514831 DOI: 10.1097/txd.0000000000001356] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/12/2022] [Accepted: 06/05/2022] [Indexed: 11/26/2022] Open
Abstract
Liver allocation in the United States was updated on February 4, 2020, by introducing the acuity circle (AC)-based model. This study evaluated the early effects of the AC-based allocation on waitlist outcomes. Methods Adult liver transplant (LT) candidates listed between January 1, 2019, and September 30, 2021, were assessed. Two periods were defined according to listing date (pre- and post-AC), and 90-d waitlist outcomes were compared. Median transplant Model for End-stage Liver Disease (MELD) score of each transplant center was calculated, with centers categorized as low- (<25 percentile), mid- (25-75 percentile), and high-MELD (>75 percentile) centers. Results A total of 12 421 and 17 078 LT candidates in the pre- and post-AC eras were identified. Overall, the post-AC era was associated with higher cause-specific 90-d hazards of transplant (csHR, 1.32; 95% confidence interval [CI], 1.27-1.38; P < 0.001) and waitlist mortality (cause-specific hazard ratio [csHR], 1.20; 95% CI, 1.09-1.32; P < 0.001). The latter effect was primarily driven by high-MELD centers. Low-MELD centers had a higher proportion of donations after circulatory death (DCDs) used. Compared with low-MELD centers, mid-MELD and high-MELD centers had significantly lower cause-specific hazards of DCD-LT in both eras (mid-MELD: csHR, 0.47; 95% CI, 0.38-0.59 in pre-AC and csHR, 0.56; 95% CI, 0.46-0.67 in post-AC and high-MELD: csHR, 0.11; 95% CI, 0.07-0.17 in pre-AC and csHR, 0.14; 95% CI, 0.10-0.20 in post-AC; all P < 0.001). Using a structural Bayesian time-series model, the AC policy was associated with an increase in the actual monthly DCD-LTs in low-, mid-, and high-MELD centers (actual/predicted: low-MELD: 19/16; mid-MELD: 21/14; high-MELD: 4/3), whereas the increase in monthly donation after brain death-LTs were only present in mid- and high-MELD centers. Conclusions Although AC-based allocation may improve waitlist outcomes, regional variation exists in the drivers of such outcomes between centers.
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Affiliation(s)
- Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Tommy Ivanics
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Toshihiro Kitajima
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Shingo Shimada
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Tayseer M. Shamaa
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Kelly Collins
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Michael Rizzari
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Atsushi Yoshida
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Dilip Moonka
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, MI
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
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6
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Organ Transportation Innovations and Future Trends. CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-021-00341-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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7
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Abstract
Since the initial report of long-term survival after lung transplantation (LT) in 1983, there has been remarkable progress in the field and LT is now the gold-standard therapy for patients with end-stage lung disease. It confers a significant survival advantage and improves the quality of life in patients who often have few other treatment options. However, LT remains a complex undertaking and establishing and maintaining an LT program is resource intensive with multiple potential barriers. In this article, we focus on disparities in LT and the potential solutions to improving access to LT.
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Affiliation(s)
- Simran K Randhawa
- Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Sophia H Roberts
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, MO, USA
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8
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Abstract
PURPOSE OF REVIEW The aim of this review is to outline disparities in liver and kidney transplantation across age spectrum. Disparities do not involve only recipients whose age may severely affect the possibility to access to a potentially life-saving procedure, but donors as well. The attitude of transplant centers to use older donors reflects on waiting list mortality and drop-out. This review examines which age categories are currently harmed and how different allocation systems may minimize disparities. RECENT FINDINGS Specific age categories suffer disparities in the access to transplantation. A better understanding of how properly evaluate graft quality, a continuous re-evaluation of the most favorable donor-to-recipient match and most equitable allocation system are the three key points to promote 'justice and equality' among transplant recipients. SUMMARY The duty to protect younger patients waiting for transplantation and the request of older patients to have access to potentially life-saving treatment urge the transplant community to use older organs thus increasing the number of available grafts, to evaluate new allocation systems with the aim to maximize 'utility' while respecting 'equity' and to avoid 'futility' thus minimizing waiting list mortality and drop-out, and improving the survival benefits for all patients requiring a transplant. VIDEO ABSTRACT http://links.lww.com/COOT/A9.
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Affiliation(s)
- Fabio Melandro
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital
| | - Serena Del Turco
- Institute of Clinical Physiology, National Research Council (CNR), Pisa, Italy
| | - Davide Ghinolfi
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital
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9
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Abstract
PURPOSE OF REVIEW The Final Rule clearly states that geography should not be a determinant of a chance of a potential candidate being transplanted. There have been multiple concerns about geographic disparities in patients in need of solid organ transplantation. Allocation policy adjustments have been designed to address these concerns, but there is little evidence that the disparities have been solved. The purpose of this review is to describe the main drivers of geographic disparities in solid organ transplantation and how allocation policy changes and other potential actions could impact these inequalities. RECENT FINDINGS Geographical disparities have been reported in kidney, pancreas, liver, and lung transplantation. Organ Procurement and Transplant Network has modified organ allocation rules to underplay geography as a key determinant of a candidates' chance of receiving an organ. Thus, heart, lung, and more recently liver and Kidney Allocation Systems have incorporated broader organ sharing to reduce geographical disparities. Whether these policy adjustments will indeed eliminate geographical disparities are still unclear. SUMMARY Modern allocation policy focus in patients need, regardless of geography. Innovative actions to further reduce geographical disparities are needed.
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Hess NR, Seese LM, Sultan I, Wang Y, Hickey GW, Kilic A. Geographic disparities in heart transplantation persist under the new allocation policy. Clin Transplant 2021; 35:e14459. [PMID: 34398485 DOI: 10.1111/ctr.14459] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 07/25/2021] [Accepted: 08/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study evaluated the impact of the 2018 heart allocation policy change on geographic disparities in United States orthotopic heart transplantation (OHT). METHODS The United Network for Organ Sharing registry was queried to measure geographic disparity in OHT rates between pre-policy and post-policy change eras. We performed multilevel Poisson regression to measure region-level OHT rates. We derived an allocation priority-adjusted median incidence rate ratio (MIRR) for each policy era, a measure of median change in OHT rates between regions. RESULTS 5958.78 waitlist person-years were analyzed, comprising 6596 OHT procedures (3890 pre-policy and 2706 post-policy). Median region-level OHT rate was .94 transplants/person-years before and 1.51 transplants/person-years after the policy change (P < .001). The unadjusted OHT MIRR across regions was 1.29 (95% CI 1.00-1.50) pre-policy change and 1.17 (95% CI 1.00-1.43) post-policy change, suggesting that the region-related variance in OHT rates decreased under the new allocation. After adjustment for allocation priority risk factors, the MIRR pre-policy change was 1.13 (95% CI 1.01-1.32) and post-policy change was 1.15 (95% CI 1.00-1.35). CONCLUSIONS Geography accounts for ∼10% of the disparity among United States OHT rates. Despite broader heart sharing, the updated allocation policy did not substantially alter the existing geographic disparities among OHT recipients.
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Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Laura M Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gavin W Hickey
- Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiac Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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11
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Braun HJ, Dodge JL, Grab JD, Glencer AC, Schwab ME, Stock PG, Hirose R, Roberts JP, Ascher NL. Live Donor Liver Transplantation in the United States: Impact of Share 35 on Live Donor Utilization. Transplantation 2021; 105:824-831. [PMID: 32433235 PMCID: PMC7980785 DOI: 10.1097/tp.0000000000003318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Share 35 was a policy implemented in 2013 to increase regional sharing of deceased donor livers to patients with model for end-stage liver disease ≥ 35 to decrease waitlist mortality for the sickest patients awaiting liver transplantation (LT). The purpose of this study was to determine whether live donor liver transplantation (LDLT) volume was impacted by the shift in allocation of deceased donor livers to patients with higher model for end-stage liver disease scores. METHODS Using Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files, we identified all adults who received a primary LT between October 1, 2008, and March 31, 2018. LT from October 1, 2008, through June 30, 2013, was designated as the pre-Share 35 era and July 1, 2013, through March 31, 2018, as the post-Share 35 era. Primary outcomes included transplant volumes, graft survival, and patient survival in both eras. RESULTS In total, 48 779 primary adult single-organ LT occurred during the study period (22 255 pre-Share 35, 26 524 post). LDLT increased significantly (6.8% post versus 5.7% pre, P < 0.001). LDLT volume varied significantly by region (P < 0.001) with regions 2, 4, 5, and 8 demonstrating significant increases in LDLT volume post-Share 35. The number of centers performing LDLT increased only in regions 4, 6, and 11. Throughout the 2 eras, there was no difference in graft or patient survival for LDLT recipients. CONCLUSIONS Overall, LDLT volume increased following the implementation of Share 35, which was largely due to increased LDLT volume at centers with experience in LDLT, and corresponded to significant geographic variation in LDLT utilization.
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Affiliation(s)
- Hillary J. Braun
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer L. Dodge
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Joshua D. Grab
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Alexa C. Glencer
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Marisa E. Schwab
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Peter G. Stock
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Ryutaro Hirose
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - John P. Roberts
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Nancy L. Ascher
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
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12
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Wahid NA, Rosenblatt R, Brown RS. A Review of the Current State of Liver Transplantation Disparities. Liver Transpl 2021; 27:434-443. [PMID: 33615698 DOI: 10.1002/lt.25964] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/16/2020] [Accepted: 12/04/2020] [Indexed: 12/19/2022]
Abstract
Equity in access is one of the core goals of the Organ Procurement and Transplant Network (OPTN). However, disparities in liver transplantation have been described since the passage of the National Organ Transplant Act, which established OPTN in the 1980s. During the past few decades, several efforts have been made by the United Network for Organ Sharing (UNOS) to address disparities in liver transplantation with notable improvements in many areas. Nonetheless, disparities have persisted across insurance type, sex, race/ethnicity, geographic area, and age. African Americans have lower rates of referral to transplant centers, females have lower rates of transplantation from the liver waiting list than males, and public insurance is associated with worse posttransplant outcomes than private insurance. In addition, pediatric candidates and older adults have a disadvantage on the liver transplant waiting list, and there are widespread regional disparities in transplantation. Given the large degree of inequity in liver transplantation, there is a tremendous need for studies to propose and model policy changes that may make the liver transplant system more just and equitable.
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Affiliation(s)
- Nabeel A Wahid
- Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | - Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
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13
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Mogul DB, Perito ER, Wood N, Mazariegos GV, VanDerwerken D, Ibrahim SH, Mohammad S, Valentino PL, Gentry S, Hsu E. Impact of Acuity Circles on Outcomes for Pediatric Liver Transplant Candidates. Transplantation 2020; 104:1627-1632. [PMID: 32732840 PMCID: PMC7319877 DOI: 10.1097/tp.0000000000003079] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND In December 2018, United Network for Organ Sharing approved an allocation scheme based on recipients' geographic distance from a deceased donor (acuity circles [ACs]). Previous analyses suggested that ACs would reduce waitlist mortality overall, but their impact on pediatric subgroups was not considered. METHODS We applied Scientific Registry of Transplant Recipients data from 2011 to 2016 toward the Liver Simulated Allocation Model to compare outcomes by age and illness severity for the United Network for Organ Sharing-approved AC and the existing donor service area-/region-based allocation schemes. Means from each allocation scheme were compared using matched-pairs t tests. RESULTS During a 3-year period, AC allocation is projected to decrease waitlist deaths in infants (39 versus 55; P < 0.001), children (32 versus 50; P < 0.001), and teenagers (15 versus 25; P < 0.001). AC allocation would increase the number of transplants in infants (707 versus 560; P < 0.001), children (677 versus 547; P < 0.001), and teenagers (404 versus 248; P < 0.001). AC allocation led to decreased median pediatric end-stage liver disease/model for end-stage liver disease at transplant for infants (29 versus 30; P = 0.01), children (26 versus 29; P < 0.001), and teenagers (26 versus 31; P < 0.001). Additionally, AC allocation would lead to fewer transplants in status 1B in children (97 versus 103; P = 0.006) but not infants or teenagers. With AC allocation, 77% of pediatric donor organs would be allocated to pediatric candidates, compared to only 46% in donor service area-/region-based allocation (P < 0.001). CONCLUSIONS AC allocation will likely address disparities for pediatric liver transplant candidates and recipients by increasing transplants and decreasing waitlist mortality. It is more consistent with federally mandated requirements for organ allocation.
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Affiliation(s)
- Douglas B Mogul
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Emily R Perito
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Nicholas Wood
- Department of Mathematics, United States Naval Academy, Annapolis, MD
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | | | - Samar H Ibrahim
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Saeed Mohammad
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Pamela L Valentino
- Section of Gastroenterology & Hepatology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Sommer Gentry
- Department of Mathematics, United States Naval Academy, Annapolis, MD
| | - Evelyn Hsu
- Department of Pediatrics, University of Washington, Seattle, WA
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Locke JE, Shelton BA, Olthoff KM, Pomfret EA, Forde KA, Sawinski D, Gray M, Ascher NL. Quantifying Sex-Based Disparities in Liver Allocation. JAMA Surg 2020; 155:e201129. [PMID: 32432699 DOI: 10.1001/jamasurg.2020.1129] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Differences in local organ supply and demand have introduced geographic inequities in the Model for End-stage Liver Disease (MELD) score-based liver allocation system, prompting national debate and patient-initiated lawsuits. No study to our knowledge has quantified the sex disparities in allocation associated with clinical vs geographic characteristics. Objective To estimate the proportion of sex disparity in wait list mortality and deceased donor liver transplant (DDLT) associated with clinical and geographic characteristics. Design, Setting, and Participants This retrospective cohort study used adult (age ≥18 years) liver-only transplant listings reported to the Organ Procurement and Transplantation Network from June 18, 2013, through March 1, 2018. Exposure Liver transplant waiting list. Main Outcomes and Measures Primary outcomes included wait list mortality and DDLT. Multivariate Cox proportional hazards regression models were constructed, and inverse odds ratio weighting was used to estimate the proportion of disparity across geographic location, MELD score, and candidate anthropometric and liver measurements. Results Among 81 357 adults wait-listed for liver transplant only, 36.1% were women (mean [SD] age, 54.7 [11.3] years; interquartile range, 49.0-63.0 years) and 63.9% were men (mean [SD] age, 55.7 [10.1] years; interquartile range, 51.0-63.0 years). Compared with men, women were 8.6% more likely to die while on the waiting list (adjusted hazard ratio [aHR], 1.11; 95% CI, 1.04-1.18) and were 14.4% less likely to receive a DDLT (aHR, 0.86; 95% CI, 0.84-0.88). In the geographic domain, organ procurement organization was the only variable that was significantly associated with increased disparity between female sex and wait list mortality (22.1% increase; aHR, 1.22; 95% CI, 1.09-1.30); no measure of the geographic domain was associated with DDLT. Laboratory and allocation MELD scores were associated with increases in disparities in wait list mortality: 1.14 (95% CI, 1.09-1.19; 50.1% increase among women) and DDLT: 0.87 (95% CI, 0.86-0.88; 10.3% increase among women). Candidate anthropometric and liver measurements had the strongest association with disparities between men and women in wait list mortality (125.8% increase among women) and DDLT (49.0% increase among women). Conclusions and Relevance Our findings suggest that addressing geographic disparities alone may not mitigate sex-based disparities, which were associated with the inability of the MELD score to accurately estimate disease severity in women and to account for candidate anthropometric and liver measurements in this study.
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Affiliation(s)
- Jayme E Locke
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham
| | - Brittany A Shelton
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham
| | - Kim M Olthoff
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Elizabeth A Pomfret
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora
| | - Kimberly A Forde
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Deirdre Sawinski
- Division of Renal and Electrolytes, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Meagan Gray
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham
| | - Nancy L Ascher
- Division of Transplantation, Department of Surgery, University of California School of Medicine, San Francisco, San Francisco
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15
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Hashimoto D, Poudel S, Hirano S, Kurashima Y, Akiyama H, Eguchi S, Fukui T, Hagiwara M, Hida K, Izaki T, Iwase H, Kawamoto S, Otomo Y, Nagai E, Saito M, Takami H, Takeda Y, Toi M, Yamaue H, Yoshida M, Yoshida S, Ohki T, Kodera Y. Is there disparity between regions and facilities in surgical resident training in Japan? Insights from a national survey. Surg Today 2020; 50:1585-1593. [PMID: 32488479 DOI: 10.1007/s00595-020-02037-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/19/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE This study sought to assess the disparity between regions and facilities in surgical resident training in Japan via a national level needs-assessment. METHODS A survey was sent to all 909 graduating residents of 2016. Residents trained in the six prefectures with a population of 7 million or more were included in the large prefecture (LP) group. Residents trained in the other 41 prefectures were included in the small prefecture (SP) group. Each group was further divided into a university hospital (UH) group and a non-university hospital (NUH) group. RESULTS The response rate was 56.3% (n = 512). Excluding nine residents who did not report their prefectures and facilities, surveys from 503 residents were analyzed. The UH group received significantly more years of training. In the SP and UH groups, there were significantly fewer residents who had performed 150 procedures or more under general anesthesia in comparison to the LP and NUH groups, respectively. Self-assessed competencies for several procedures were significantly lower in the SP and UH groups. CONCLUSION Disparity in surgical resident training was found between regions and facilities in Japan. The surgical residency curriculum in Japan could be improved to address this problem.
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Affiliation(s)
- Daisuke Hashimoto
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata-city, Osaka, 573-1010, Japan. .,Department of Gastroenterological Surgery, Omuta Tenryo Hospital, Fukuoka, Japan. .,Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medicine, Kumamoto, Japan.
| | - Saseem Poudel
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hirotoshi Akiyama
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Masaru Hagiwara
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | - Koya Hida
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomoko Izaki
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hirotaka Iwase
- Department of Breast and Endocrine Surgery, Kumamoto University, Kumamoto, Japan
| | - Shunsuke Kawamoto
- Division of Cardiovascular Surgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Eishi Nagai
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mitsue Saito
- Department of Breast Oncology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hideki Takami
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuko Takeda
- Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan
| | - Masakazu Toi
- Department of Breast Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Motofumi Yoshida
- Department of Medical Education, Graduate School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Shigetoshi Yoshida
- Department of Thoracic Surgery, International University of Health and Welfare School of Medicine, Narita, Japan
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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16
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Parker WF, Chin MH. Epistemic Authority and Trust in Shared Decision Making About Organ Transplantation. AMA J Ethics 2020; 22:E408-415. [PMID: 32449657 DOI: 10.1001/amajethics.2020.408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Patient epistemic authority acknowledges respect for a patient's knowledge claims, an important manifestation of patient autonomy that facilitates shared decision making in medicine. Given the scarcity of deceased donor organs, transplantation programs state that patient promises of compliance cannot be taken at face value and exclude candidates deemed untrustworthy. This article argues that transplant programs frequently lack the data to make this utilitarian calculation accurately, with the result that, in practice, the psychosocial evaluation of potential transplant candidates is discriminatory and unfair. Historically excluded candidates, such as patients suffering from alcohol use, have turned out to benefit highly from transplantation. Transplant programs should tend to trust patients when they claim to be good potential organ stewards, thereby respecting patient autonomy, advancing justice, and saving more lives.
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Affiliation(s)
- William F Parker
- Instructor of pulmonary and critical care medicine, senior fellow at the MacLean Center for Clinical Medical Ethics at the University of Chicago in Illinois
| | - Marshall H Chin
- Richard Parrillo Family Professor of Healthcare Ethics in the Department of Medicine, associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago in Illinois
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17
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18
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Taner T, Heimbach JK. We (Now) Know What We Are, But Not What We May Be. Transplantation 2019; 103:1978-1979. [PMID: 31568230 DOI: 10.1097/tp.0000000000002644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Timucin Taner
- Division of Transplant Surgery, Mayo Clinic College of Medicine, Rochester, MN
| | - Julie K Heimbach
- Division of Transplant Surgery, Mayo Clinic College of Medicine, Rochester, MN
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