Geographic Disparity in Organ Distribution

Where you live should not determine whether you live or die while waiting for an organ. 

Unfortunately, the nation’s organ allocation system continues to make an already dire situation worse by creating geographic disparities in access to organs for transplant: people living in some parts of the country wait far longer and are sicker when they receive an organ than those in other parts of the country. Consequently, hundreds of Americans needlessly die every year while waiting for organs. 

Background

America’s organ transplant system is overseen by the United Network for Organ Sharing (UNOS), a private, nonprofit organization chartered by the U.S. Health Resources and Services Administration (HRSA) to oversee the national transplant system and ensure equitable organ allocation. Long ago, UNOS divided the country into 11 regions. 

Under current rules, the sickest liver patients are ranked at the top of local waiting lists within their UNOS region. Organs from a deceased donor are given to the sickest person in that region, even if there are sicker patients in greater need elsewhere in the nation. In many states, this leads to far fewer organs than in other parts of the country—and far more avoidable deaths. It also enables more affluent patients needing liver transplants to get on shorter waiting lists by traveling to areas with better access to healthy organs. 

The Data

Under the current local distribution system, research indicates that there is wide disparity in a candidate’s chances of receiving a liver. For example, one study found that for patients who were equally sick, 90-day transplant rates ranged from 18% to 86% across DSAs. That study also highlighted that among candidates with MELD scores between 21 and 34, the probability of transplant within 90 days for candidates with the same score varied widely across OPOs, ranging from under 30% to over 90%.

Additional evidence of the ongoing disparity can be seen through the higher overall death rates in places where patients have to wait longer to receive a life-saving transplant. For patients with very high MELD scores, findings indicate a 90-day probability of waitlist death, ranging widely from 14% in some DSAs to 82% in others. Patients who have to wait longer to receive a transplant also have a higher chance of dying after the procedure, as pre-transplant MELD score have been demonstrated to correlate inversely with posttransplant survival. The staggering statistics demonstrate that the costs of waiting for candidates in some areas have indeed been high, lowering their chances of survival both before and after transplant.

Conclusion

Every candidate for a life-saving liver transplant should have an equal shot at getting one. Federal policy intends that livers for transplant from deceased donors be allocated evenly across the entire nation based on need. Despite this noble purpose, evidence clearly demonstrates that critical gaps in our current distribution policy hinders realization of these goals. As the well-documented disparities in liver distribution linger, our shared values of equality in access to organ transplant cannot be achieved, and patients in some places must continue to wait a long time, get too sick, or die before they can receive a transplant.

References

Koizumi N, Ganesan R, Gentili M, et al. Redesigning Organ Allocation Boundaries for Liver Transplantation in the United States. Proceedings of the International Conference on Health Care Systems Engineering / Andrea Matta, Jingshan Li, Evren Sahin, Ettore Lanzarone, John Fowler, editors International Conference on Health Care Systems Engineering (2013 : Milan, . 2014;61:15-27. doi:10.1007/978-3-319-01848-5_2.

Massie AB, Caffo B, Gentry SE, et al. MELD exceptions and rates of waiting list outcomes. Am J Transplant 2011; 11(11): 2362–2371.

Yeh H, Smoot E, Schoenfeld DA, Markmann JF. Geographic inequity in access to livers for transplantation. Transplantation. 2011; 91(4):479–486.

Habib, S., Berk, B., Chang, C.-C. H., Demetris, A. J., Fontes, P., Dvorchik, I., Eghtesad, B., Marcos, A. and Shakil, A. O. (2006), MELD and prediction of post–liver transplantation survival. Liver Transpl, 12: 440–447. doi:10.1002/lt.20721.

Billy Wynne