title: United Network for Organ Sharing regional variations in appeal denial rates with non-standard Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease exceptions: support for a national review board.
abstract: Although it has been generally recognized that there are inconsistencies among Regional Review Boards in the assignment of points for model for end-stage liver disease (MELD)/pediatric end-stage liver disease (PELD) exception patients with resulting considerable variation in appeal denial rates, data to actually prove this have been limited. We reviewed 6533 MELD/PELD exception applications submitted between 2005 and 2008, calculated the variation in approval/denial rates, and followed these cases through mid-2013 to assess the effects on patient outcomes. We found highly significant regional variations in denial rates for appeals by exception patients and in transplantation rates. The odds of transplant for patients whose appeals are approved is 2.45 times that of patients not approved; that this effect does not vary by region suggests that the variation in transplant rates is driven, at least in part, by the variation in appeal denial rates. Health deterioration or death accounts for more than two-thirds of wait list removals among patients removed for reasons other than transplant. Our findings add to the weight of evidence that a national review board that uses current clinical expertise, peer review literature, and data to consistently assign priority could reduce regional inequities and move toward equitable allocation of organs and compliance with the United States Department of Health & Human Services Final Rule.
authors: Liver Transplant Program, Stanford University Medical Center, Stanford, CA, USA.|St. Joseph's Hospital Medical Center/Liver Center, University of Phoenix, Phoenix, AZ, USA.
authors: Robert G
authors: RG
authors: Gish
authors: Division of Gastroenterology and Hepatology, Alameda Health System-Highland Hospital, Oakland, CA, USA.
authors: Robert J
authors: RJ
authors: Wong
authors: Clinical and Translational Research Institute, University of California San Diego, San Diego, CA, USA.
authors: Gordon
authors: G
authors: Honerkamp-Smith
authors: Clinical and Translational Research Institute, University of California San Diego, San Diego, CA, USA.|Department of Family and Preventive Medicine, University of California San Diego, San Diego, CA, USA.
authors: Ronghui
authors: R
authors: Xu
authors: Barry S. Levin Department of Transplantation, California Pacific Medical Center, San Francisco, CA, USA.
authors: Robert W
authors: RW
authors: Osorio
mesh_terms: D000328:Adult; D026683:Advisory Committees; D002648:Child; D058625:End Stage Liver Disease / Q000401:mortality / Q000601:surgery*; D005260:Female; D015276:Health Care Rationing / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D016031:Liver Transplantation / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012720:Severity of Illness Index; D014481:United States; D014850:Waiting Lists
keywords: appeal; denial; equitable; liver transplantation; model for end-stage liver disease; non-recognized exceptional diagnoses; non-standard; organ allocation; recognized exceptional diagnoses; regional review board; regional variation