Share 35 changes in center-level liver acceptance practices

Abstract

Share 35 was implemented to provide improved access to organs for patients with Model for End-Stage Liver Disease (MELD) scores ≥ 35. However, little is known about the impact of Share 35 on organ offer acceptance rates. We evaluated all liver offers to adult patients who were ultimately transplanted between January 1, 2011 and December 31, 2015. The analyses focused on patients ranked in the top 5 positions of a given match run and used multilevel mixed-effects models, clustering on individual wait-list candidate and transplant center. There was a significant interaction between Share 35 era and MELD category (P < 0.001). Comparing offers to MELD score ≥ 35 patients, offers after Share 35 were 36% less likely to be accepted compared with offers to MELD score ≥ 35 patients before Share 35 (adjusted odds ratio, 0.64). There was no clinically meaningful difference in the donor risk index of livers that were declined for patients with an allocation MELD score ≥35 in the pre- versus post-Share 35 era. Organ offer acceptance rates for patients with an allocation MELD ≥ 35 decreased in every region after Share 35; the magnitude of these changes was bigger in regions 2, 3, 4, 5, 6, 7, and 11, compared with regions 8 and 9 that had regional sharing in place before Share 35. There were significant changes in organ offer acceptance rates at the center level before versus after Share 35, and these changes varied across centers (P < 0.001). In conclusion, in liver transplantation candidates achieving a MELD score ≥ 35, liver acceptance of offers declined significantly after implementation of Share 35. The alterations in behavior at the center level suggest that practice patterns changed as a direct result of Share 35. Changes in organ acceptance under even broader organ sharing (redistricting) would likely be even greater, posing major logistical and operational challenges, while potentially increasing discard rates, thus decreasing the total number of transplants nationally. Liver Transplantation 23 604-613 2017 AASLD.

Conflict of interest statement

Conflicts of Interest: The authors of this manuscript have no conflicts of interest to disclose as it pertains to this manuscript.

© 2017 by the American Association for the Study of Liver Diseases.

Figures

Figure 1

a. Figure 1a: Changes in unadjusted acceptance rates by donor quality and share type i. Legend: Pre-Share 35 Post-Share 35 b. Figure 1b: Reason for declines of organ offers to patients with an allocation MELD score ≥35 in the pre- and post-Share 35 eras i. Legend: Pre-Share 35 Post-Share 35 c. Figure 1c: Forest plot of odds ratios from multivariable model for organ offer acceptances based on allocation MELD score and era

Figure 1

a. Figure 1a: Changes in unadjusted acceptance rates by donor quality and share type i. Legend: Pre-Share 35 Post-Share 35 b. Figure 1b: Reason for declines of organ offers to patients with an allocation MELD score ≥35 in the pre- and post-Share 35 eras i. Legend: Pre-Share 35 Post-Share 35 c. Figure 1c: Forest plot of odds ratios from multivariable model for organ offer acceptances based on allocation MELD score and era

Figure 1

a. Figure 1a: Changes in unadjusted acceptance rates by donor quality and share type i. Legend: Pre-Share 35 Post-Share 35 b. Figure 1b: Reason for declines of organ offers to patients with an allocation MELD score ≥35 in the pre- and post-Share 35 eras i. Legend: Pre-Share 35 Post-Share 35 c. Figure 1c: Forest plot of odds ratios from multivariable model for organ offer acceptances based on allocation MELD score and era

Figure 2

Donor risk index of liver offers pre- and post-Share 35 based on allocation MELD score of patient and organ offer decision

Figure 3

a. Figure 3a: Among-region changes in unadjusted acceptance rates pre- vs post-Share 35 by allocation MELD score for all deceased-donors b. Figure 3b: Among-region changes in unadjusted acceptance rates pre- vs post-Share 35 by allocation MELD score for all brain-dead deceased-donors

Δ acceptance rates for allocation MELD<35

Δ acceptance rates for allocation MELD≥35

Δ acceptance rates for Status 1

Figure 3

a. Figure 3a: Among-region changes in unadjusted acceptance rates pre- vs post-Share 35 by allocation MELD score for all deceased-donors b. Figure 3b: Among-region changes in unadjusted acceptance rates pre- vs post-Share 35 by allocation MELD score for all brain-dead deceased-donors

Δ acceptance rates for allocation MELD<35

Δ acceptance rates for allocation MELD≥35

Δ acceptance rates for Status 1

Figure 3

a. Figure 3a: Among-region changes in unadjusted acceptance rates pre- vs post-Share 35 by allocation MELD score for all deceased-donors b. Figure 3b: Among-region changes in unadjusted acceptance rates pre- vs post-Share 35 by allocation MELD score for all brain-dead deceased-donors

Δ acceptance rates for allocation MELD<35

Δ acceptance rates for allocation MELD≥35

Δ acceptance rates for Status 1

Figure 4

a. Figure 4a: Changes in adjusted center-level liver acceptance rates pre- vs post-Share 35 for patients with an allocation MELD score

Note: Each dot represents the change in a center’s adjusted liver acceptance rates (Adjusted acceptance rate for patients with an allocation MELD score <35 post-Share 35) – (Adjusted acceptance rate for patients with an allocation MELD score <35 pre-Share 35)

b. Figure 4b: Changes in adjusted center-level liver acceptance rates pre- vs post-Share 35 for patients with an allocation MELD score ≥35

1. Note: Each dot represents the change in a center’s adjusted liver acceptance rates (Adjusted acceptance rate for patients with an allocation MELD score ≥35 post-Share 35) – (Adjusted acceptance rate for patients with an allocation MELD score ≥35 pre-Share 35)

Figure 4

a. Figure 4a: Changes in adjusted center-level liver acceptance rates pre- vs post-Share 35 for patients with an allocation MELD score

Note: Each dot represents the change in a center’s adjusted liver acceptance rates (Adjusted acceptance rate for patients with an allocation MELD score <35 post-Share 35) – (Adjusted acceptance rate for patients with an allocation MELD score <35 pre-Share 35)

b. Figure 4b: Changes in adjusted center-level liver acceptance rates pre- vs post-Share 35 for patients with an allocation MELD score ≥35

1. Note: Each dot represents the change in a center’s adjusted liver acceptance rates (Adjusted acceptance rate for patients with an allocation MELD score ≥35 post-Share 35) – (Adjusted acceptance rate for patients with an allocation MELD score ≥35 pre-Share 35)