title: One Size Does Not Fit All--Regional Variation in the Impact of the Share 35 Liver Allocation Policy.
abstract: Allocation policies for liver transplantation underwent significant changes in June 2013 with the introduction of Share 35. We aimed to examine the effect of Share 35 on regional variation in posttransplant outcomes. We examined two patient groups from the United Network for Organ Sharing dataset; a pre-Share 35 group composed of patients transplanted between June 17, 2012, and June 17, 2013 (n = 5523), and a post-Share group composed of patients transplanted between June 18, 2013, and June 18, 2014 (n = 5815). We used Kaplan-Meier and Cox multivariable analyses to compare survival. There were significant increases in allocation Model for End-stage Liver Disease (MELD) scores, laboratory MELD scores, and proportions of patients in the intensive care unit and on mechanical, ventilated, or organ-perfusion support at transplant post-Share 35. We also observed a significant increase in donor risk index in this group. We found no difference on a national level in survival between patients transplanted pre-Share 35 and post-Share 35 (p = 0.987). Regionally, however, posttransplantation survival was significantly worse in the post-Share 35 patients in regions 4 and 10 (p = 0.008 and p = 0.04), with no significant differences in the remaining regions. These results suggest that Share 35 has been associated with transplanting "sicker patients" with higher MELD scores, and although no difference in survival is observed on a national level, outcomes appear to be concerning in some regions.
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY.
authors.forename: K J
authors.initials: KJ
authors.lastname: Halazun
authors.affiliation: Department of Surgery and Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ.|Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, AZ.
authors.forename: A K
authors.initials: AK
authors.lastname: Mathur
authors.affiliation: Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: A A
authors.initials: AA
authors.lastname: Rana
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.|Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.
authors.forename: A B
authors.initials: AB
authors.lastname: Massie
authors.affiliation: Center for Liver Disease and Transplantation, Columbia University Medical Center, NY Presbyterian Hospital, New York, NY.
authors.forename: S
authors.initials: S
authors.lastname: Mohan
authors.affiliation: Emory Transplant Center, Emory University Hospital, Atlanta, GA.
authors.forename: R E
authors.initials: RE
authors.lastname: Patzer
authors.affiliation: Emory Transplant Center, Emory University Hospital, Atlanta, GA.
authors.forename: J P
authors.initials: JP
authors.lastname: Wedd
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY.
authors.forename: B
authors.initials: B
authors.lastname: Samstein
authors.affiliation: Emory Transplant Center, Emory University Hospital, Atlanta, GA.
authors.forename: R M
authors.initials: RM
authors.lastname: Subramanian
authors.affiliation: Emory Transplant Center, Emory University Hospital, Atlanta, GA.
authors.forename: B D
authors.initials: BD
authors.lastname: Campos
authors.affiliation: Duke Transplant Center, Duke University Hospital, Durham, NC.
authors.forename: S J
authors.initials: SJ
authors.lastname: Knechtle
mesh_terms: D005260:Female; D006084:Graft Rejection / Q000453:epidemiology / Q000517:prevention & control*; D006085:Graft Survival; D006801:Humans; D017093:Liver Failure / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011050:Policy Making; D017410:Practice Guidelines as Topic / Q000592:standards*; D040841:Resource Allocation / Q000379:methods*; D014019:Tissue Donors; D009927:Tissue and Organ Procurement / Q000592:standards*; D014850:Waiting Lists
keywords: United Network for Organ Sharing (UNOS); clinical research/practice; liver transplantation/hepatology; organ allocation; registry/registry analysis