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Enhancing Liver Distribution

Enhancing Liver Distribution. Liver and Intestinal Organ Transplantation Committee. What is the proposed current policy proposal?. Proximity circles with 150-mile radius around the donor hospital Circles may extend out of the region

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Enhancing Liver Distribution

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  1. Enhancing Liver Distribution Liver and Intestinal Organ Transplantation Committee

  2. What is the proposed current policy proposal? • Proximity circles with 150-mile radius around the donor hospital • Circles may extend out of the region • Expanded regional sharing, Share 29 to candidates within the region and/or circle • 5 MELD or PELD points to candidates within the circle • Separate allocation for DCD donors and donors at least 70 years old

  3. Proposed allocation schema: Allocation of adult livers, non-DCD and age <70

  4. Addition of Proximity points: • Candidates within the 150-nautical mile circle receive 5 MELD or PELD proximity points • Candidates in the circle (both in and out of region) receive proximity MELD or PELD points

  5. Separate allocation for specific deceased donors: • New allocation for DCD or age > 70 donors • Prioritize local (DSA) allocation for this subset of donors

  6. Additional details: • Regional sharing will be “Region or Circle” for allocating all livers and liver-intestines (adult and pediatric) • Candidates at programs within 150 miles of the donor hospital, and outside the region, would be included in “Region or Circle” allocation. • “Regional allocation” will potentially include candidates outside the region (but within the proximity circle) • Non-DCD pediatric donor livers: sharing within the region or circle for pediatric donors. • Status 1A and 1B candidates in the circle do not receive additional priority

  7. Supporting Evidence • Share 35 has increased access to urgent (MELD/PELD > 35) candidates • Proximity points will prevent livers traveling beyond 150 miles for small differences in MELD or PELD points • Region + Circle sharing does not rely on supply and demand metrics • Livers can travel to urgent candidates beyond DSA and regional boundaries • Without the potential logistical issues of sharing more broadly

  8. Summary of National LSAM Data: Current vs Proposal • Variance in the MMaT: All candidates 10 to 6 • Allocation MMaT: 29 to 29 • Median Transport Time (hours): 1.7 to 1.74 • Median Distance Organs Travel (miles): 88.5 to 100.7 • Percent Organs Flown: 50.7 to 55.2 • Transplant Rate/Count : 0.444/6651 to 0.437/6651 • Waiting List Mortality Rate/Count: 0.097/1455 to 0.090/1366 • Post TxMortality Rate/Count: 0.077/686 to 0.077/682

  9. Region 3 specific data

  10. DSA Transplant count

  11. DSA Waitlist mortality count

  12. Region 3 DSA % allografts flown

  13. What other models did we consider? • Project start in 2012: included 5 subcommittees plus 2 consensus conferences • District model– optimizing supply and demand metrics into 4 and 8 districts designed with an eye on not increasing travel but improving disparity in MMaT. • Concern that this was too big of a change, and the data used to develop the supply and demand metrics was outdated • Neighborhood model– a series of adjacent DSAs around the donor hospital • Travel was increased significantly compared to current system. Complex • 250/500 concentric circle around the donor hospital • Travel was increased significantly compared to current system. Significant change from current model as DSA and regions go away.

  14. What else have we done in preparation for broader sharing? • National Liver Review Board has been developed and passed by the Board of Directors • This may reduce concern that differences between regions are actually due to unjustified, non-standard exceptions • Changes to HCC policy (which previously had significant regional variation) have also been adopted

  15. How will members implement this proposal? • New relationships for liver transplant programs and OPOs outside their current region • Train OPO and Transplant Center staff on changes • No additional data collection required.

  16. How will the OPTN implement this proposal? • Anticipated Board of Directors Review: Dec. 2017 • Significant programming effort • Educational opportunities to explain new distribution • Robust monitoring plan at 3-month intervals • Will share data with community • Recent changes to HCC and NLRB expected to be implemented before this proposal

  17. Specific feedback requested • Size of the proximity circle– should it be larger? Vary by population density? • Number of proximity points– 5, or 3 or 0? • Providing proximity points to the candidates in the circle - and in the recovery DSA? • Sharing threshold of lab MELD 29 for adult candidates– use a lower/higher threshold? • Separate allocation for DCD and age > 70 years old– agree? • Addressing the cap at MELD 40– when points are added for those with 36 and higher, should they all be at 40, or should they be ranked (41, 42, 43, etc…)? • Points only apply to candidates with a MELD or PELD of 15

  18. Questions? Julie Heimbach, MD Committee Chair heimbach.julie@mayo.edu Matt Prentice, MPH Committee Liaison Matthew.prentice@unos.org

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