A 6‐Month Report on the Impact of the Organ Procurement and Transplantation Network/United Network for Organ Sharing Acuity Circles Policy Change

Abstract

On February 4, 2020, the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) implemented a new liver and intestinal organ distribution system called the “acuity circles” (AC) model. The primary impetus for this change was concern that donor service area (DSA) and regional boundaries were a major contributor of geographic disparities in liver transplantation (LT).(1) The data cited by the OPTN Board of Directors to support this model were based on the Scientific Registry of Transplant Recipients (SRTR) 2018 analysis report that predicted that the AC model would decrease the variance in median Model for EndStage Liver Disease (MELD) at transplant (MMAT) across DSAs, the primary cited measure of geographic inequity in LT.(1,2) The model predicted a substantial decrease from 9.97 to 4.33 based on historical data.(1,2) We used OPTN/UNOS data to evaluate centerlevel and DSAlevel changes in several key metrics in the 6month period preAC (August 8, 2019 to February 3, 2020) and the 6month postAC periods, allowing for a 1month adjustment period to the new AC system (March 5, 2020 to August 31, 2020). We focused on adult deceased donor LT (DDLT) recipients (excluding Status 1 patients) to evaluate metrics similar to the SRTR analysis report(1,2): (1) transplant volume (absolute and relative), (2) MMAT, and (3) procurements where the distance from the transplant hospital to donor hospital would be expected to require a flight (cutoff of 100 miles based on data from the SRTR as OPTN/UNOS does not catalog data on flights(3)), termed “flightconsistent distance” procurements. The volume of adult nonstatus 1 DDLT transplant decreased by 92 (2.7%; 3406 to 3314). The percentage of adult DDLT recipients with MELD exceptions decreased from 795 (23.4% of all adult DDLTs) to 654 (19.8%; P < 0.001). Of the 52 DSAs with a LT center, the median change in adult DDLT volume was +1 DDLT. However, there was wide variation ranging from −40 (41.2% decrease) in MIOP to +26 (74.3% increase) in CASD. There were 9 DSAs that had a decrease in adult DDLT volume ≥15 transplants (relative decrease ranging from 12.8% to 41.2% in these DSAs PATF, FLMP, GALL, PADV, INOP, LAOP, TXSB, AZOB, and MIOP), of which 7 had a decrease in both exception and nonexception adult DDLT recipients. Conversely, 9 DSAs had an increase ≥15 transplants (relative increase of 12.9% to 95.2%; CADN, KYDA, VATB, ILIP, NYRT, MNOP, NYFL, OHLB, and CASD), of which all 9 had an increase in the volume of nonexception DDLT recipients, yet 5 had a decrease in their volume of exception point recipients. Abbreviations: AC, acuity circles; COVID19, coronavirus disease 2019; DDLT, deceased donor liver transplantation; DSA, donor service area; LT, liver transplantation; MELD, Model for EndStage Liver Disease; MMAT, median MELD at transplant; OPTN, Organ Procurement and Transplantation Network; SRTR, Scientif ic Registry of Transplant Recipients; UNOS, United Network for Organ Sharing.