The impact of geographic location versus center practice on center volume in liver transplantation after the acuity circle policy.

Abstract

The allocation system for livers used the acuity circles (AC) beginning in 2020. In this study, we sought to evaluate the effect of the AC policy on center transplant volumes, from geographic and center practice perspectives. Using the US national registry data between 2018 and 2022, adult liver transplantations (LTs) were separated into two eras: before AC and after AC. The number of LT for Model for End-Stage Liver Disease (MELD) scores ≥29 have significantly increased by 10%, and waitlist times for those patients have been significantly shorter after AC. These benefits were not found in patients with MELD scores<29. The geographic distribution of transplant centers reveals that the majority of centers which increased their transplant volume (18 out of 25 centers) are located in high-population states while there are seven transplant centers in nonhigh-population states. The centers in the nonhigh-population states utilized more marginal donation after brain death (DBD) and donation after circulatory death (DCD) donors by 27% and 155%, respectively. MELD scores were significantly lower in the nonhigh-population states compared with those in the high-population states (p<.01). AC improved the LT access for patients with MELD scores ≥29, which benefited the high-population states. However, aggressive center practices to utilize marginal DBD and DCD donors were able to increase transplant volume and lower median allocation MELD scores.