More Money and More Miles: The Hidden Costs of Donor Procurement with the New Heart Allocation System

Abstract

In October 2018, the United Network for Organ Sharing (UNOS) implemented extensive changes to the adult heart allocation policy. These changes were developed to better stratify medically urgent patients and provide more equitable geographic distribution of donor hearts. Instead of preferential distribution within a local donor service area, hearts are first considered by centers within 500 nautical miles of a donor hospital. We evaluated the impact of the new system on the mode and associated expense of procurement travel. We retrospectively analyzed data from 5 centers across 5 states and 4 UNOS regions (regions 2, 5, 10, 11). Pre-allocation change (pre-change) was considered 10/1/2016-10/17/2018 and post-allocation change (post-change) was considered 10/18/18-8/31/2019. The share of procurements requiring a flight vs local transportation from all centers was compared. Cost of transportation for procurement and distance from donor hospital to transplant center was available from 4 centers. Total of 693 transplants were performed during the study period: 477 pre-change and 216 post-change. Pre-change, there were 274 flights for procurement compared to 182 flights post-change (57 vs 84%, p <0.0001). There were notable differences in these increases by UNOS region (Figure). Average travel increased from 193 miles pre-change to 269 miles post-change (p<0.0001), corresponding with an increase in average transportation costs from $6,812.07 to $12,383.64 (p<0.0001), respectively. Following the 2018 UNOS change to the heart allocation system, the proportion of flights and distance traveled for organ procurements significantly increased across 5 moderate-high volume centers, nearly doubling the average travel cost for procurement. These findings may guide transplant centers, payers, and policy makers regarding necessary procurement resources. Further study is needed to determine how these changes may affect lower volume centers with fewer resources.