The unacceptable geographic disparities in who gets a new organ

By Jason Millman wapo

More than 123,000 Americans are on the waiting list for a new organ. Where they live could determine whether they have a better shot at a life-saving transplant.

Just take liver donations, which are now being scrutinized by federal policymakers. The wait for a liver transplant alone killed about 1,523 people in 2013, according to a federal agency overseeing organ transplant policy. Nearly the same amount of people were taken off the waiting list for a new liver last year because they were determined too sick to receive a transplant.

Liver donations are awarded to patients with the greatest need, but geography also plays a role. The national transplant system overseen by the Organ Procurement and Transplantation Network divides up the country into 11 geographical regions, which are further divided up into donation service areas.

This creates a system in which the neediest candidate on the waiting list doesn’t necessarily receive the next-available liver. This issue came to the forefront about five years ago, when late Apple chief executive Steve Jobs traveled from California to Tennessee for a liver transplant — where wait times are shorter.

Nowthe U.S. panel overseeing transplant policy is examining reforms to the system for distributing new livers. The United Network for Organ Sharing, a nonprofit monitoring transplants for the federal government, held a meeting this week in Chicago to review possible solutions for reducing the geographic disparity in liver donations. After labeling the geographic disparities “unacceptably high” in 2012, the group released a concept paper in June examining different options for redesigning the liver transplant network and followed that up this month with a survey of the organ transplant community.

To see what this geographic disparity looks like, a 2011 study in the American Journal of Transplantation shows that across these donation service areas, the likelihood of receiving a transplant varies considerably for people with the same MELD scores — the measurement for determining who’s most in need of a liver transplant. For instance, a person with a 38 MELD, which represents one of the higher mortality rates in this scoring system, has an 18 percent chance of receiving a liver in one donation service area, versus an 86 percent chance in another.


The following map shows the median MELD score — or just how sick the patient was — at the time of transplant across donation service nationwide. A lower score indicates a healthier patient, so you see parts of the country where those patients have better access to new livers.


One of the options that transplant advocates are now weighing includes redrawing the donation map into either four or eight districts. One analysis found that reducing the number of districts to four would mean 554 fewer wait list deaths over a five-year period.

But there is a political fight brewing over potential changes to the transplant rules. In a letter to federal health officials earlier in the week, more than 50 lawmakers expressed concern that redrawing the donation district maps would disproportionately benefit urban areas along the coasts while limiting the supply in the Midwest and South. The informal survey from UNOS, the organ oversight group, found there’s strong support for redistricting, but support varies among the existing regions for organ donations.

UNOS is still taking feedback on the issue, and it will be months before the group could possibly make a formal proposal. Liver donations are just the start, though. The group is also planning to look at the effect of geography on all types of organs. Reviews for pancreas and kidney transplants, which is the most common procedure, will likely come later because of “substantially new policies” soon taking effect for those transplants, said UNOS spokesman Joel Newman.

“The thought for those is to see how the new policies function, and what changes they bring, for some time before considering further revisions based on geographic issues,” Newman said.

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