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Published on: March 8, 2024
Regional variations in peer reviewed liver allocation under the MELD system
Hector Rodriguez-Luna1, Hugo E Vargas, Adyr Moss
1Transplantation Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA.
Abstract:
The Model for End-Stage Liver Disease (MELD) is used to assign priority for liver transplantation candidates. The Organ Procurement and Transplantation Network (OPTN) approved recognized exceptional diagnoses (RED's) for which MELD fails to accurately measure priority. Centers can request increased MELD points in cases not recognized by this policy (non-RED's). Our aim was to compare regional practices to justify non-RED requests for MELD adjustments. The UNOS/OPTN database was queried to extract all adult cases for which a non-RED MELD adjustment was requested from 2/27/02 until 8/27/03. The data were stratified by region and justification. Data for 29,510 listings were available. 26,947 had complete diagnosis information. There were 827 non-RED requests of which 477 (57.7%) petitions were approved by the regional review boards (RRBs). The approval rate varied significantly among regions (range: 28-75%, p<0.0001). The most common non-RED's were complications of portal hypertension (48%). The percentage of patients listed with non-RED's varied significantly among regions (0.7-8.3 %, p<0.0001), as did the proportion of patients transplanted with non-RED's (2.1-31.9%, p<0.0001). Demographics did not differ among regions requesting non-REDs.Widespread regional variations exist in the handling of requests for non-REDs. These variations point to the need for reform to standard exception criteria.
Insights
Regional variations in approving non-MELD exception requests for liver transplant priority highlight a need for standardized criteria. Approval rates for these critical MELD adjustments varied widely, impacting patient access to transplantation.
Area of Science:
- Hepatology
- Transplantation Medicine
- Health Services Research
Background:
- The Model for End-Stage Liver Disease (MELD) score is crucial for liver transplant candidate prioritization.
- Recognized Exceptional Diagnoses (REDs) allow MELD score adjustments, but non-RED requests address unlisted conditions.
- Existing policies may not accurately reflect transplant priority for all conditions.
Purpose of the Study:
- To compare regional practices in justifying and approving non-RED MELD adjustment requests.
- To identify variations in the application of exception criteria for liver transplant candidates.
- To provide data supporting the need for standardized exception policies.
Main Methods:
- Utilized the UNOS/OPTN database to extract adult cases with non-RED MELD adjustment requests (2/27/02 - 8/27/03).
- Stratified data by geographic region and justification for requests.
- Analyzed approval rates by regional review boards (RRBs) and patient demographics.
Main Results:
- Of 827 non-RED requests, 57.7% were approved, with significant regional variation in approval rates (28-75%, p<0.0001).
- Complications of portal hypertension were the most common reason for non-RED requests (48%).
- Significant regional disparities existed in the percentage of patients listed with non-REDs (0.7-8.3%) and transplanted with non-REDs (2.1-31.9%).
Conclusions:
- Widespread regional variations in handling non-RED MELD exception requests were observed.
- These inconsistencies suggest a need for policy reform to standardize exception criteria.
- Standardization is essential for equitable liver transplant candidate prioritization.
