In policy and in practice: expedited placement and allocation out of sequence in liver transplantation

United States liver transplant policy debate has conflated two distinct mechanisms: Expedited Placement (OPTN Policy 9.10), a formal route for late turndowns when in-sequence offering risks non-utilization, and allocation out-of-sequence (AOOS), informal organ procurement organization (OPO) outreach beyond the match-run. Linking Standard Transplant Analysis and Research files to the Potential Transplant Recipient database (March 2021-December 2025), we classified 61,626 match-runs (41,638 transplanted) by pathway: in-sequence <50 offers (n=32,165), in-sequence ≥50 (n=3,450), AOOS (n=5,486), and Expedited Placement (n=537). AOOS rose 132% while Expedited Placement grew 6% and was absent in 12 of 55 OPOs. Before acceptance, a median 10 centers were contacted per AOOS graft versus 6 in-sequence, and AOOS refusals far more often covered entire waitlists (median 28 patients declined per donor versus 2). Most in-sequence acceptances occurred before donor cross-clamp (median 17.0 hours prior), whereas AOOS and Expedited Placement acceptances occurred after (0.15 and 2.42 hours). AOOS transplants occurred more frequently at centers with higher in-sequence acceptance of hard-to-place organs (Spearman 0.866), with comparable survival. These patterns are consistent with AOOS occurring after in-sequence placement has stalled, rather than as early bypass of in-sequence candidates; the circumstance Expedited Placement was designed for.