Differences in Access to Liver Transplantation: Disease Severity, Waiting Time, and Transplantation Center Volume

15 May 2007 | Volume 146 Issue 10 | Pages 707-713

Background: The Model for End-Stage Liver Disease (MELD) score has been used since February 2002 to allocate livers for transplantation from deceased donors according to medical need. Allocation based on MELD scores should ensure that sicker patients receive transplants first regardless of transplantation center volume.

Objective: To determine whether the MELD score at transplantation and waiting time of liver transplant recipients differs by transplantation center volume.

Design: Analysis of the Organ Procurement and Transplantation Network database. Centers were classified according to the volume of transplantations performed in 2005: high (100 transplantations), medium (50 to 99 transplantations), and low (<50 transplantations).

Setting: Transplantation centers in the United States.

Patients: 20 075 transplant recipients between 27 February 2002 and 30 April 2006.

Measurements: MELD scores and waiting times of liver transplant recipients.

Results: Transplant recipients at high-volume centers had lower MELD scores (35.1% with MELD scores 18 vs. 22.7% and 27.0% at medium- and low-volume centers, respectively; P < 0.001), and the median MELD score was 22 compared with 24 at both medium- and low-volume centers. Despite having lower MELD scores, recipients at high-volume centers also experienced shorter waiting times (median waiting time, 69 days vs. 98 days and 94 days at medium-and low-volume centers, respectively; P < 0.001).

Limitations: The definition of transplantation center volume was subjective. The recent implementation of MELD precluded analysis of differences in long-term outcomes related to waiting time or center volume.

Conclusions: The MELD scores and waiting time of liver transplant recipients differed by transplantation center volume. High-volume centers have shorter waiting times and perform more transplantations for less sick patients. The reasons for these differences are unclear but warrant further investigation.

Editors' Notes Context Under the current system of organ allocation, sicker patients with liver disease get higher priority for liver transplants. Contribution Using national data, the investigators found that patients waiting for transplants at higher-volume transplantation centers received transplants at lower disease severity scores and have shorter waiting times than patients waiting for transplants at lower-volume transplantation centers. Caution The study could not determine whether the observed differences led to differences in clinical outcomes. Implications Although the current liver allocation system is need-based, transplantation priority still differs by transplantation center. Patients listed at higher-volume centers seem to receive transplants at lower disease severity scores and with shorter delays. —The Editors

 

Author and Article Information

From the Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, Pennsylvania.

Disclaimer: The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the U.S. Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government.

Acknowledgments: The authors thank Chung-Chou H. Chang, PhD, for guidance with the statistical methods and Maxwell Farrell, BS, for completing the bootstrapping programs.

Grant Support: In part by the Health Resources and Services Administration (contract 231-00-0115). Dr. Bryce is supported by the National Institute for Diabetes and Digestive and Kidney Diseases (5K25 DK-002903-05).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Jawad Ahmad, MD, Division of Gastroenterology and Hepatology, University of Pittsburgh, 3471 Fifth Avenue, Suite 916, Pittsburgh, PA 15213; e-mail, ahmadj{at}msx.upmc.edu.

Current Author Addresses: Dr. Ahmad: Division of Gastroenterology and Hepatology, University of Pittsburgh, 3471 Fifth Avenue, Suite 916, Pittsburgh, PA 15213.

Drs. Bryce and Roberts: Section for Decision Sciences and Clinical Systems Modeling, Division of General Internal Medicine, University of Pittsburgh, 200 Meyran Avenue, Pittsburgh, PA 15213.

Dr. Cacciarelli: Pittsburgh Veterans Affairs Healthcare System, University Drive, Pittsburgh, PA 15240.

Author Contributions: Conception and design: J. Ahmad, C.L. Bryce, M.S. Roberts.

Analysis and interpretation of the data: J. Ahmad, C.L. Bryce, T. Cacciarelli, M.S. Roberts.

Drafting of the article: J. Ahmad, C.L. Bryce, T. Cacciarelli.

Critical revision of the article for important intellectual content: J. Ahmad, C.L. Bryce, M.S. Roberts.

Final approval of the article: J. Ahmad, C.L. Bryce, T. Cacciarelli, M.S. Roberts.

Statistical expertise: J. Ahmad, C.L. Bryce.