1. MELD Exception Scores During NLRB Transition
Executive Committee
The Committee added this proposal for a special public comment cycle.

2. What problem will the proposal solve?
Circle-based median MELD at transplant (MMaT) would result in some transplant hospitals in the same DSA with different MMaTs
While allocation is still based on DSA and region, this would disadvantage certain exception patients
It will address a problem the committee identified that would affect certain exception candidates during the transition period between implementation of NLRB and implementation of allocation changes 3 months later.
4 DSAs and 10 transplant programs would be affected.

3. What is the proposed solution?
Award exception points relative to MMaT by DSA
The award of exception points relative to MMaT by DSA will only be used during this ~1 month transition period (ending April 30), while DSAs are still used as units of distribution. After the transition period, MMaT within 250nm will be used according to the liver policy approved in December 2018 (Acuity Circles).
Since allocation will still be by DSA and region until the allocation changes are implemented, the committee proposes using MMaT in the DSA for awarding exception points. This is the proposal out for public comment.
This would ONLY be used during the transition, and then MMaT within 250 nm will be used when livers are allocated by acuity circles.

4. Other solutions considered
Delay implementation of NLRB so that there is no transition period
Eliminates transition problem, but uses some exception scores assigned in the old system while allocating under Acuity Circles.
National MMaT during the transition period
Treats everyone the same, but doesn’t help candidate in areas that have less access
Manually adjust MMaT for the affected transplant hospitals
Solves for the affected centers, but treats candidates at a small subset of centers differently
Leave as MMaT/250 during the transition period. (Current Board approved)
Leaves the candidates in the 4 affected DSAs on unequal footing during the transition
Delay implementation:
This option would remove the 3-month delay between implementation of the NLRB changes and implementation of allocation changes. This option would address the specific problem of allocation using DSA while scores are based on a different geographic area by eliminating the period of time when that would be the case.
 It would also cause the transition of candidates from their current scores to MMaT-based scores to take place under the new allocation sequence; this would result in offers made under the new allocation to candidates based on the old scoring system. The Committee wanted to avoid this result, and so did not favor this option.
The Committee considered using the national MMaT during the transition period, since it would be unaffected by the distribution unit. However, the purpose of using a localized MMaT was to factor in the differences in the ability to access transplant across the country. A score based on a national MMaT would not grant the same chance of transplant to candidates in areas where the local MMaT is high that it would in areas with a lower local MMaT. This would result in diminished access for exception candidates in DSAs with a high MMaTs and diminished access for non-exception candidates in DSAs with low MMaTs. As variation in access across the country improves, a national MMaT would be beneficial; however, the Committee did not recommend this solution because currently it would negatively impact access across the country.
 Manually adjust MMaT for the affected transplant hospitals.
The Committee considered using a different score in place of MMaT/250 only for candidates in the four affected DSAs. This might be assigning all of the candidates in a DSA the highest MMaT/250 within the DSA or the lowest MMaT/250 in the DSA. This would solve the problem of assigning different exception scores to similar candidates during the transition period, but would create a fractured system that could be difficult to explain to members and candidates. The Committee did not pursue this option because it placed a high value on transparency, especially with regard to an interim solution that would not be subject to public comment.
Leave as MMaT/250 during the transition period. (Current Board approved)
The Committee also considered whether there was even a need to adopt a different transition plan. It is possible to use MMaT/250 beginning with the implementation of scoring changes. This would have the advantage of being easy to explain. It also would result in more similar scores among transplant hospitals in a single region compared to MMaT/DSA. On the other hand, it would not eliminate the differences in MMaT among transplant hospitals in the four affected DSAs, or all of the differences in MMaT among transplant hospitals in the same regions. The Committee believed the difference in exception scores within the DSA would directly result in candidates losing access to transplant during the transition period. The Committee did not think it was acceptable to leave the differences in MMaT within a DSA during the transition period, so it did not recommend this option.

5. How will the OPTN implement this proposal?
Provide updated MMaT values before implementation
Assign exception scores relative to the MMaT in the DSA during the transition
When the ~1-month transition period is over (April 30), and MMaT in the 250nm circle and Acuity Circles are implemented, the candidates’ scores will be converted, and all MMaT-based exception scores will be changed at the same time.
When the NLRB is initially implemented using MMaT in the DSA, candidates WILL NOT be converted on the first day. Instead, they will be assigned scores based on MMaT as they apply for an extension of an existing exception or apply for a new exception.
When the transition period is over, and MMaT in the 250nm circle and Acuity circles are implemented, the candidates’ scores WILL be converted, and all MMaT-based exception scores will be changed at the same time.
A current cohort of scores for MMaT by DSA and for MMaT by 250nm circle will be posted in the toolkit on the OPTN site. (Under resources, select Liver & Intestine to get to the toolkit.)
Both may be updated prior to implementation with a more recent cohort of data, but the posted scores should give you an idea for planning and educating patients on generally what to expect.
Initially, scores will only be converted from the current system to based on MMaT in the DSA as candidates are due for an extension of their exception or apply for a new exception.
When scores are converted from MMaT in the DSA to MMaT within 250nm, scores will all be converted at the same time.

6. Is the Committee seeking feedback?
Should exceptions scores assigned prior to implementation of the NLRB be converted when the new allocation system is implemented?
Transition period: about 1/3 of all existing exceptions will be due for extension, and will be converted to scores based on MMaT within 250NM when Acuity Circles takes effect
After transition: remaining 2/3 of exceptions would still have scores assigned under the regional review board system
These are the scores that could potentially be converted

7. Questions?