A major federal policy change in allocating donor livers four years ago has led to decreased transplant volumes and increased hospital costs, particularly for transplant centers in lower-income states and those serving larger proportions of racial and ethnic minorities. Those are the main findings of a study recently published in JAMA Surgery with participation from Vanderbilt University Medical Center.
The cross-sectional study compared two 12-month periods, one before and one after the United Network for Organ Sharing (UNOS) adopted a new liver allocation policy in February 2020. The new policy changed liver allocations from a regional service area to an “acuity circles” system that assigns donor livers as far as 500 nautical miles away based on the acuity of recipients. This disadvantaged transplant centers such as Vanderbilt, where regional donation rates are higher than in other parts of the country, particularly large urban centers in the Northeast.
“These policies were put in place by UNOS in some cases with the majority of geographic regions in opposition due to concerns of increased cost, discarded organs and logistical complexity,” said Seth Karp, MD, professor and chair of the Section of Surgical Sciences at VUMC and former director of the Vanderbilt Transplant Center and an author of the trans-institutional study. “There is now substantial data to support these concerns.”
Researchers invited 68 transplant centers nationwide to participate, and 22 responded, representing all parts of the country. Those centers showed a 6% volume decrease in transplanted livers. It also showed that local organs were being allocated to centers farther away, requiring transplant centers such as Vanderbilt to import organs from farther away and at greater cost. The study also showed a marked increase in the number of “dry runs,” or patients called into the hospital for a transplant that does not end up happening because of the organ’s condition or other factors.
Transplants using local organ donations decreased 54%, the study found, while imported donations after brain death increased 133%. Imported “fly-outs,” or organs so far away they required airplane transport, and dry runs increased 163%. Overall hospital costs at participating centers increased 10.9%, including a 77% increase in fly-out costs.
Health disparities for historically disadvantaged populations also increased. Centers that served larger proportion of racial and ethnic minorities, specifically Black transplant candidates, had increased costs by more than 90% for imported livers, fly-outs and dry runs despite a drop in the number of liver transplants.
The authors concluded that the new UNOS liver allocation policy may have the unintended effect of disproportionately increasing transplant costs for regions with greater disparities in health care.
“Our report raises serious concerns that the current discoverable changes could deprive underserved and disadvantaged populations,” the authors stated. “Finally, the increased flying is striking: it requires greater time and energy and puts personnel at risk. 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.”
