New LT allocation policy increases cost by 10.9% overall, 13.9% in underserved areas
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Key takeaways:
- After the new UNOS allocation policy, there was a 5.7% decrease in transplant volume and a 7.2% increase in liver discards.
- Overall hospital costs increased by 10.9%, for a total of $46,360,176.
The new United Network for Organ Sharing liver allocation policy has resulted in a significant increase in the number and cost of liver imports, with greater costs incurred by low-income states and underserved areas, according to analysis.
“Recently, a major change in allocation occurred in February 2020 from a model based on donation service area to a system using acuity circles of 500 nautical miles from the donor hospital,” Ola Ahmed, MD, PhD, of the division of abdominal organ transplantation at Washington University School of Medicine, and colleagues wrote in JAMA Surgery. “There is significant concern that the new liver model has increased transplant costs. ... Drivers of access inequality are multifactorial, but increasing costs to an already disadvantages population could be highly problematic.”
In a cross-sectional study, researchers compared data on LT volume and cost from 22 transplant centers before (March 2019-March 2020) and after (March 2020-March 2021) the new UNOS allocation policy. These center responses accounted for 18.6% of adult centers in the U.S. and 22.5% of the national volume.
According to analysis, there was a 5.7% decrease in overall LT volume from the period before (n = 1,948) to after (n = 1,837) the policy and a 7.2% increase in liver discards, from 792 to 903 livers.
While transplants using local donations after brain death decreased by 54%, imported donations increased by 133%. Similarly, local liver fly-outs and dry runs did not change, but imported fly-out volume and dry-run fly-outs increased 163% (median, 19 vs. 50) and 33% (median, 3 vs. 7), respectively.
Overall hospital and fly-out costs increased by 10.9% and 77%, respectively, resulting in total increases of $46,360,176 and $10,600,234 for participating centers.
Among centers with decreased post-policy LT volume, researchers reported higher overall hospital costs ($41,720,365), with a 122% cost increase for liver imports ($6,508,480). Centers from low-income states and those serving a larger population of racial and ethnic minority patients had 12% and 13.9% increased hospital costs and 94% and 92.4% increased import costs.
“This analysis paints a very concerning picture of the most recent UNOS allocation system,” Ahmed and colleagues wrote. “First, transplants increased less than donor numbers, suggesting higher discard rates. Next, costs increased dramatically, as much as a quarter of a billion dollars, combined with increased logistical complexity. Our report raises serious concerns that the current discoverable changes could deprive underserved and disadvantaged populations.”
They continued, “We are concerned that further major changes, in particular, the continuous allocation policies being promoted by UNOS without sufficient justification, could worsen an already broken system.”
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