Raymond Lynch-Led Study Describes Link to More Deaths for Vulnerable Patients Under UNOS Proposals for Broader Liver Sharing
Emory transplant surgeon Raymond Lynch, MD, presented a study at the American Transplant Congress in Chicago on May 2 which concluded that proposals by the United Network for Organ Sharing (UNOS) to more evenly share livers on the basis of apparent need may instead increase waitlist mortality among already underserved populations. He conducted the study with David Goldberg, MD, MSCE, a gastroenterologist from the University of Pennsylvania; Katherine Ross, MPH, an Emory epidemiology PhD student; and Rachel Patzer, PhD, MPH, the director of Emory's Transplant Health Services and Outcomes Research Program.
The proposed UNOS change redistricts the current 11-region system to eight regions, expanding the geographic areas in which a limited number of organs are allocated. Opponents of the proposal believe that this revision will cause donated livers from socially disadvantaged areas to be diverted from local recipients and sent to areas of greater privilege, an opinion that is given further weight by the the study results.
While regional organ availability is frequently discussed in allocation policy, the impact on waitlist mortality of community-level factors and access to transplant centers remains poorly understood. The study shows that adverse local health and economic conditions and increased travel distance do appear to increase waitlist mortality, and reflect underlying disparities that should be addressed in future allocation policies since these risk factors are not uniform across UNOS regions.
"Multiple studies have documented the lower rate at which minorities are waitlisted and transplanted," says Dr. Lynch. "Patients of lower socioeconomic status already have a higher waitlist death rate as well as reduced access to high-volume, high-quality transplant centers."
Dr. Lynch and his colleagues evaluated 114,347 liver transplant candidates listed in the Scientific Registry of Transplant Recipients between 2002 and 2014 and found that a travel distance of greater than 25 miles from a transplant center was associated with increased mortality. Using Community Health Scores to track socioeconomic disadvantage, they also found that poverty, minority race, and rural residence independently predicted reduced access and increased mortality. Models created by UNOS would deflect livers from patients living in these areas due to the redrawn regions.
"Simply put, our study shows the more underserved your community and/or the farther you live from a transplant center, the greater your chances of dying while waiting for a transplant," says Dr. Lynch. "People living in these areas are recognized by Congress as deserving special study and protection. Unfortunately, in attempting to fix one aspect of transplantation, the proposed redistricting plan would predominantly reduce access and increase risk for the most vulnerable patients. We need to use this as an opportunity to redesign distribution in a way that recognizes individual risk and fulfills our obligation to underserved communities."