The demand for transplantable organs in the United States has long outpaced the supply. Right now, more than 16,000 people across the country are waiting for liver transplants.
Unfortunately, the nation’s organ allocation system has historically made 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.
This can and must change. Fortunately, a new policy adopted by the federally designated organization responsible for overseeing organ distribution, will, when implemented, install a set of sensible, lifesaving improvements to the current system. Despite strong opposition, the policy – referred to as the “Acuity Model” – was adopted because it is the best solution available for ensuring equitable access to life saving transplantations.
Historic Geographic Inequalities in the Liver Distribution System
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 the rules historically used to determine organ distribution, the sickest liver patients were ranked at the top of local waiting lists within their UNOS region. Organs from a deceased donor were given to the sickest person in that region, even if there were sicker patients in greater need elsewhere in the nation. In many states, this led to far fewer organs than in other parts of the country—and far more avoidable deaths. It also enabled more affluent patients needing liver transplants to get on shorter waiting lists by traveling to areas with better access to healthy organs.
The UNOS Board of Directors asked its Liver Committee to explore a solution. A more just and equitable system—using modern organ preservation technology—would permit organs to cross regional borders and be given to patients with the greatest medical need. And in December 2018, they authorized a new policy that would create just that.
The map above identifies – in blue and green – the regions of the country where patients tend to be at much more advanced stages of liver disease before they receive an organ for transplant, the chief indicator for regions where access is the most limited and avoidable deaths are most common.
Identifying a Solution to Reduce Inequities and Save Lives
In response to the recommendations of an Institute of Medicine Committee directed by Congress to address this issue 15 years ago, and under the belief that “geographic disparities in candidate access to liver transplants are unacceptably high,” the UNOS Liver Committee produced a concept document, Redesigning Liver Distribution to Reduce Variation in Access to Liver Transplantation, which outlined approaches to reducing the number of liver donation regions from the 11 that exist today to either four or eight.
The Liver Committee’s analysis was rooted in comprehensive research and data. Its models suggested that sharing livers within four broader zones would save at least 554 lives over five years. Total costs would decline by 4.3%, or about $246 million, “due to the decrease in the cost of pre-transplant care.”
The concept document also stated that there is no relationship between poor organ procurement performance in a given area and geographical differences in access to livers—and under a system of four or eight liver donation regions there would still be no relationship. Finally, reducing the number of regions would not reduce organ donations. In a 2013 survey, 82% of respondents said they would prefer that organs go to the person in greatest medical need, regardless of location.
This concept document ultimately informed the “Acuity Model,” which OPTN and UNOS voted overwhelmingly to adopt in December 2018. Within the model is embedded the same science and methodology that carried strong evidence of its promise to save money and lives.
Please Act to Protect the Improvements Achieved in Organ Distribution Equity
The new liver allocation policy adopted by OPTN is slated to go into effect on May 1, 2019. It is imperative that this policy be upheld so that U.S. patients can realize the benefits. We cannot allow the current system to persist, under which significant geographic disparities are unfairly impacting residents in certain areas.
Unfortunately, long-standing, aggressive opponents of change have already announced their intention to block implementation of the Acuity Model by any means necessary, including through legislation and a likely lawsuit. These stakeholders, acting upon a mistaken understanding and the desire to maintain the status quo, seek to dismantle the promising strides toward equity. We must act to prevent such an outcome, and ensure that the Liver Committee’s groundbreaking work, based on science, and with the primary goal of improving equity nationwide, be maintained.