The sickest first? Disparities with model for end-stage liver disease-based organ allocation: one region's experience

February 27, 2002, allocation of cadaver livers for transplantation changed from a waiting-time-based system to an evidence-based system referred to as the Model for End-Stage Liver Disease (MELD). We reviewed data from 1 of the 11 United Network for Organ Sharing regions to determine the impact of the MELD on the allocation of cadaver livers for transplantation in that region. The region of interest (study region) consists of three distinct geographic areas (referred to as Transplant Service Areas [TSAs]). Based on information obtained from the Organ Procurement and Transplantation Network for the United States and for the study region, the following observations were made: (1) study region patients who received a cadaver liver had higher mean and median MELD scores than cadaver liver recipients in the United States (study region mean score, 25.1; median, 26.0; US mean score, 23.9; median, 24.0); (2) within the study region, TSAs with competing liver transplant programs performed transplantation on patients at a significantly higher mean MELD score than TSAs dominated by a single center (TSA-1 mean score, 27.3; TSA-2 mean score, 26.6; TSA-3 mean score, 21.3); this disparity persisted when transplantations for hepatocellular carcinoma (HCC) were excluded; and (3) study region patients removed from the waiting list because of death or being too sick for transplantation have higher MELD scores than the national average (study region mean score, 25.4; US mean score, 23.8). Overall, implementation of the MELD resulted in a substantial increase in the number of transplantations performed for HCC, and MELD exceptions for all reasons were more common in TSAs that have multiple centers. Despite the MELD, there remains disparity in organ allocation within the study region. The MELD may accurately predict pretransplantation mortality, but it does not ensure equitable organ distribution. We propose that intraregional sharing of cadaver livers based on the MELD may help limit disparities in organ allocation.