Liver and Intestinal Organ Transplantation Committee Spring 2014 Update

 Share 15/share 35/national share for combined liver-intestine candidates – implemented June 17, 2013  Committee monitor impact of these changes  HCC imaging criteria: October 31, 2013 Policy Implementation

Adding serum sodium to the MELD score  Public comments: 78.6% supported  Regional votes/comments: 8 in favor, 2 opposed, 1 approved with amendment  ASTS supported, AST opposed  Board did not approve; Committee will resubmit proposal in June 2014 Recent Public Comment Proposals

Ongoing Committee Initiatives

Designing Liver Distribution for Geographic Equity

Motivation: Transplant Rates, by OPO MELD 38-39: 18% to 86% Massie/Segev, AJT 2011

Motivation: Death Rates, by OPO MELD 38-39: 14% to 82% Massie/Segev, AJT 2011

Final rule: “Neither place of residence nor place of listing shall be a major determinant of access to a transplant.”

Nov 2012 OPTN board resolution ** RESOLVED, that the Board of Directors approve the following position regarding geography in organ allocation:  The existing geographic disparity in allocation of organs for transplant is unacceptably high.  The Board directs the organ-specific committees to define the measurement of fairness and any constraints for each organ system by June 30, The measurement of fairness may vary by organ type but must consider fairness based upon criteria that best represent patient outcome.  The Board requests that optimized systems utilizing overlapping versus non-overlapping geographic boundaries be compared, including using or disregarding current DSA boundaries in allocation.

 2011: SRTR asked to further explore optimization algorithms  2012 OPTN Strategic Plan, Objective A: Reduce geographic disparities in access to transplantation  Strategy: Promote broader distribution of organs  Key initiatives:  Examine SRTR study of regional boundary effects on liver distribution  Examine the effectiveness of the current DSA and regional boundaries and consider developing a new method for distribution of organs to replace the use of DSAs and regions Designing Liver Distribution for Geographic Equity - Recent Activity

 November 2012: Board tasks Committees w/ Disparity Metrics  Liver Committee Metric: Variance of median MELD at transplant across DSAs  March 2013: Liver Committee Key Decisions  Number of districts between 4 and 8  Minimum number of transplant centers per district: 6  Waitlist deaths must not be statistically significantly higher Designing Liver Distribution for Geographic Equity - Recent Activity (Cont’d)

 September 2013: Reviewed drafts of maps  Next steps:  Continued evaluation of impact of redistricting and comparison between 4 and 8 districts  Impact on pediatric patients  Impact on minorities  Waiting list deaths by DSA/District  Shift in livers by DSA/District  Will report out as more decisions are made  Gentry, et al, AJT, August 2013 Designing Liver Distribution for Geographic Equity – Committee Progress Report

Broader Issues for Discussion  Impacts of OPO performance  Committee and POC discussing overarching issues  Administrative Regions/RRBs  Contiguous/ non-contiguous  Multiorgan issues  Role of DSA?  Organs other than livers – metrics? Designing Liver Distribution for Geographic Equity

 The Committee will meet on April 1, 2014  Review latest maps  Cost data to be available  Stay tuned Update

 Review of MELD/PELD exceptions and RRB practices  Working on guidelines for new standardized exceptions  Training materials for RRBs  National Review Board Ongoing Committee Initiatives

 David Mulligan, MD, Committee Chair  James Pomposelli, MD, PhD Region 1 Representative  Ann Harper, Committee Liaison Questions?