The Impact of Elimination of the Donor Service Area (DSA) on United States Lung Transplant Practices and Outcomes at High and Low Competition Centers

Abstract

On November 24, 2017, the DSA was removed as the primary unit of lung transplant allocation in the United States. We sought to examine the effects of center competition on recipient demographics, resource utilization, and outcomes before and after this change. This was a retrospective cohort study of adults in the SRTR database who underwent lung transplant in the year before or after DSA elimination. Pre- and post-DSA groups were compared using standard analytic tests. The Herfindahl Hirschman Index (HHI), a measure of market competition, was calculated, and centers in the lowest and highest HHI tertiles were identified. A difference-in-differences analysis was performed to assess the relative effects of the DSA change at these centers. The cohort included 4771 recipients (Table 1). In the post era recipients were less likely to have Group A diseases (31.0% vs 27.9%, p=0.02), and median waitlist times were shorter (p<0.001). There was no significant difference in pre-transplant ECMO, post-transplant length of stay (LOS), or prolonged ventilation between eras. Ischemic times increased with competition, but there was no increase in single lung transplants or ECMO use at high competition centers (Table 2). There was no difference in complication rates, including prolonged ventilation, post-transplant dialysis or airway dehiscence between low and high competition centers. Eliminating the DSA did not significantly affect pre-transplant resource utilization, LOS, or important complications. Effects were similar at low and high competition centers.