Waitlist Time Research Articles

Increasing waiting times for status 2 patients in new United Network for Organ Sharing allocation system: Impact on waitlist and posttransplant outcomes

ObjectiveSince the heart transplant allocation policy change in 2018, there has been an increase in temporary mechanical circulatory support for Status 2 patients. We sought to examine the temporal pattern of waitlist and posttransplant outcomes for Status 2 patients. MethodsAdult patients in the United Network for Organ Sharing registry who were listed as Status 2 from January 2019 to June 2022 were included. Temporal trends in waitlist time, waitlist events, and posttransplant outcomes were assessed. Probability of transplant or death after being listed was compared over time. Multivariable regression was performed to identify risk factors for mortality after transplant. ResultsA total of 6310 patients were included. From 2019 to 2022, the number of Status 2 patients listed increased from 4.2 to 5.9 per day. Microaxial ventricular assist devices at Status 2 listing increased over time (P < .001). During the study period, median waitlist time (18 days vs 23 days, P < .001) as well as Status 2 days (8 days vs 12 days, P < .001) increased. Waitlist mortality remained stable (5.5%); however, probability of transplant within 90 days of Status 2 listing progressively declined (P < .001). Finally, longer waitlist duration was independently associated with 30-day posttransplant mortality (odds ratio, 1.01; 95% confidence interval, 1.00-1.01, P = .02). ConclusionsSince the allocation policy change there has been a steady rise in the number of patients listed for Status 2. This has led to increasing waitlist times and lower probability of transplantation for Status 2 patients, which may have negative consequences for posttransplant outcomes.

Impact of the Pediatric ABO Policy Change on Listings, Transplants, and Outcomes for Children Younger Than 2 Years Listed for Heart Transplantation in the United States

We assessed the impact of the liberalized ABO pediatric policy change on candidate characteristics and outcomes for children undergoing heart transplant (HT). Children <2 years undergoing HT with ABO strategy reported at listing and HT from December 2011 to November 2020 to the Scientific Registry of Transplant Recipients database were included. Characteristics at listing, HT, and outcomes during the waitlist and post-transplant were compared before the policy change (December 16, 2011 to July 6, 2016), and after the policy change (July 7, 2016 to November 30, 2020). The percentage of ABO-incompatible (ABOi) listings did not increase immediately after the policy change (P = .93); however, ABOi transplants increased by 18% (P < .0001). At listing, both before and after the policy change, ABOi candidates had higher urgency status, renal dysfunction, lower albumin, and required more cardiac support (intravenous inotropes, mechanical ventilation) than those listed ABO compatible (ABOc). On multivariable analysis, there were no differences in waitlist mortality between children listed as ABOi and ABOc before the policy change (adjusted hazard ratio [aHR] 0.80, 95% confidence interval [CI] 0.61-1.05, P = .10) or after the policy change (aHR 1.2, 95% CI 0.85-1.6, P = .33). Post-transplant graft survival was worse for ABOi transplanted children before the policy change (aHR 1.8, 95% CI 1.1-2.8, P = .014), but not significantly different after the policy change (aHR 0.94, 95% CI 0.61-1.4, P = .76). After the policy change, ABOi listed children had significantly shorter waitlist times (P < .05). The recent pediatric ABO policy change has significantly increased the percentage of ABOi transplantations and decreased waitlist times for children listed ABOi. This change in policy has resulted in broader applicability and actual performance of ABOi transplantation with equal access to ABOi or ABOc organs, and thus eliminated the potential disadvantage of only secondary allocation to ABOi recipients.

Utilization of the percutaneous left ventricular support as bridge to heart transplantation across the United States: In-depth UNOS database analysis

Intra-aortic balloon pump (IABP) and Impella device utilization as a bridge to heart transplantation (HTx) have risen exponentially. We aimed to explore the influence of device selection on HTx outcomes, considering regional practice variation. A retrospective longitudinal study was performed on a United Network for Organ Sharing (UNOS) registry dataset. We included adult patients listed for HTx between Oct 2018 and April 2022 as status 2, as justified by requiring IABP or Impella support. The primary endpoint was successful bridging to HTx as status 2. Of 32,806 HTx during the study period, 4,178 met inclusion criteria (Impella n = 650, IABP n = 3,528). Waitlist mortality increased from a nadir of 16 (in 2019) to a peak of 36 (in 2022) per thousand status 2 listed patients. Impella annual use increased from 8% in 2019 to 19% in 2021. Compared to IABP, Impella patients demonstrated higher medical acuity and lower success rate of transplantation as status 2 (92.1% vs. 88.9 %, P < 0.001). The IABP: Impella utilization ratio varied widely between regions, ranging from 1.77 to 21.31, with high Impella use in Southern and Western states. However, this difference was not justified by medical acuity, regional transplant volume, or waitlist time and did not correlate with waitlist mortality. The shift in utilizing Impella as opposed to IABP did not improve waitlist outcomes. Our results suggest that clinical practice patterns beyond mere device selection determine successful bridging to HTx. There is a critical need for objective evidence to guide tMCS utilization and a paradigm shift in the UNOS allocation system to achieve equitable HTx practice across the United States.

Uptake and 1-year outcomes of lung transplantation for COVID-19

ObjectiveEnd-stage lung disease from severe COVID-19 infection is an increasingly common indication for lung transplantation (LT), but there are limited data on outcomes. We evaluated 1-year COVID-19 LT outcomes. MethodsWe identified all adult US LT recipients January 2020 to October 2022 in the Scientific Registry for Transplant Recipients, using diagnosis codes to identify recipients transplanted for COVID-19. We used multivariable regression to compare in-hospital acute rejection, prolonged ventilator support, tracheostomy, dialysis, and 1-year mortality between COVID-19 and non-COVID-19 recipients, adjusting for donor, recipient, and transplant characteristics. ResultsLT for COVID-19 increased from 0.8% to 10.7% of total LT volume during 2020 to 2021. The number of centers performing LT for COVID-19 increased from 12 to 50. Recipients transplanted for COVID-19 were younger; were more likely to be male and Hispanic; were more likely to be on a ventilator, extracorporeal membrane oxygenation support, and dialysis pre-LT; were more likely to receive bilateral LT; and had higher lung allocation score and shorter waitlist time than other recipients (all P values < .001). COVID-19 LT had higher risk of prolonged ventilator support (adjusted odds ratio, 2.28; P < .001), tracheostomy (adjusted odds ratio 5.3; P < .001), and longer length of stay (median, 27 vs 19 days; P < .001). Risk of in-hospital acute rejection (adjusted odds ratio, 0.99; P = .95) and 1-year mortality (adjusted hazard ratio, 0.73; P = .12) were similar for COVID-19 LTs and LTs for other indications, even accounting for center-level differences. ConclusionsCOVID-19 LT is associated with higher risk of immediate postoperative complications but similar risk of 1-year mortality despite more severe pre-LT illness. These encouraging results support the ongoing use of LT for COVID-19–related lung disease.

Twenty-year survival following lung transplantation.

Lung transplantation median survival has seen improvements due to recognition of short-term survival factors but continues to trail behind other solid organs due to limited understanding of long-term survivorship. Given the creation of the United Network for Organ Sharing (UNOS) database in 1986, it was difficult to accrue data on long-term survivors until recently. This study characterizes factors impacting lung transplant survival beyond 20 years, conditional to 1-year survival. Lung transplant recipients listed in UNOS from 1987 to 2002 who survived to 1 post-transplant year were reviewed. Kaplan-Meier and adjusted Cox regression analyses were performed at 20 and 10 years to identify risk factors associated with long-term outcomes independent of their short-term effects. A total of 6,172 recipients were analyzed, including 472 (7.6%) recipients who lived 20+ years. Factors associated with increased likelihood of 20-year survival were female-to-female gender match, recipient age 25-44, waitlist time >1 year, human leukocyte antigen (HLA) mismatch level 3, and donor cause of death: head trauma. Factors associated with decreased 20-year survival included recipient age ≥55, chronic obstructive pulmonary disease/emphysema (COPD/E) diagnosis, donor smoking history >20 pack-years, unilateral transplant, blood groups O&AB, recipient glomerular filtration rate (GFR) <10 mL/min, and donor GFR 20-29 mL/min. This is the first study identifying factors associated with multiple-decade survival following lung transplant in the United States. Despite its challenges, long-term survival is possible and more likely in younger females in good waitlist condition without COPD/E who receive a bilateral allograft from a non-smoking, gender-matched donor of minimal HLA mismatch. Further analysis of the molecular and immunologic implications of these conditions are warranted.

CARC20: Intra-operative Use of Intra-aortic Balloon Pump to Generate Pulsatile Flow During Heart Transplantation

Introduction: The physiologic impact of pulsatile flow (PF) on end-organ perfusion during cardiopulmonary bypass (CPB) is controversial. One method of generating PF during CPB is to use an intra-aortic balloon pump (IABP). Maintaining the IABP during CPB to produce a state of PF for patients undergoing heart transplantation (HT) may impact end-organ perfusion, with implications for short-term graft function and immediate post-operative outcomes. Methods: A single-center retrospective cohort study of adult patients bridged to HT with IABP was conducted between January 2018 and December 2022. Patients were excluded if they were <18 years old, not bridged to HT with IABP, or underwent simultaneous multi-organ transplant. For patients bridged to HT with IABP, beginning in May 2022 the IABP was allowed to continue inflating and deflating during CPB. Upon initiation of CPB, the IABP was set on an internal rate of 80 beats per minute. Patients who underwent HT with IABP turned off while on CPB (IABP-Off) and patients maintained on IABP during HT (IABP-On) were propensity matched according to age, organ ischemia time, and intraoperative dobutamine dose (mcg/kg/min). Results: A total of 70 patients bridged to HT with IABP were propensity matched into IABP-Off (n=12) versus IABP-On (n=12) groups. IABP-Off and IABP-On groups were similar with respect to age (p=0.93), sex (p=0.54), race (p=0.68), BMI (p=0.37), previous sternotomy (p=0.27), and waitlist time (p=0.31). IABP-Off and IABP-On groups had similar organ ischemia times (166.9±40.3 vs. 165.8±55.0 minutes, p=0.96), similar CPB times (109.3±20.6 vs. 111.3±29.7 minutes, p=0.43), and similar case lengths (449.5±108.7 vs. 449.4±115.3 minutes, p=0.50). The groups received similar amounts of intraoperative products and fluids. IABP-Off and IABP-On groups were matched on intraoperative dobutamine dose (2.85±1.73 vs. 3.09±1.76, p=0.74) and received similar doses of other intraoperative inotropes, with the IABP-Off group trending towards a higher norepinephrine dose that did not reach statistical significance. There was no difference in the first measured post-operative lactate between groups, although patients in the IABP-On group had significantly lower peak lactates in the first 24 hours post-transplant (2.39±1.17 vs. 4.31±2.95, p=0.02). There was no difference between groups with respect to post-operative creatinine or length of stay or mortality. Conclusion: Patients maintained on IABP had lower peak lactates in the first 24 hours post-transplant compared to patients in whom IABP was turned off and trended to require less norepinephrine. This limited preliminary data suggests that maintaining pulsatility during CPB may result in improved end-organ perfusion. Table 1. Characteristics of the IABP-Off and IABP-On Cohorts

P7: The Impact of Impella 5.5 as Bridge to Transplant at a Medium Volume Cardiac Transplant Program

Purpose: The changes in the 2018 UNOS heart allocation policy has allowed sicker patients to be prioritized while awaiting transplantation. Traditionally, bridging patients with cardiogenic shock to cardiac transplantation has used inotropes, intraaortic ballon pumps (IABP) or durable ventricular assist devices (VAD). Impella 5.5 has emerged as a new modality of support to bridge patients with HF NYHA Class IV/D, SCAI C/D to cardiac transplant. We analyzed the impact of Impella 5.5 in bridging patients to transplantation at Tampa General Hospital (TGH) in 2022, specifically looking at the impact on waitlist time, post-transplant ICU length of stay (LOS), total LOS, and complications while on support. Methods: We retrospectively analyzed our center’s cohort of Impella 5.5 supported patients who were bridged to a heart transplant in 2022 as compared to all patients recieving heart transplant in our program to evaluate median time to transplant on support, ICU and total LOS post-transplant. In 2022, a total of 60 patients in cardiogenic shock were supported with Impella 5.5. Of these, 16 patients were bridged to transplantation. In total, this represented 32% (16/50) of our transplanted patients. The majority were male (15/16), average age of 52, 10/15 supported on Impella 5.5 and inotropes, 12/16 blood type 0, 5/16 had ischemic etiology. Median time on Impella 5.5 support prior to transplant was 13 days at TGH vs 19 days in the 2022 Abiomed registry. The overall median time in hospital prior to transplant during 2022 at TGH was 12 days. Post-transplant ICU LOS for Impella 5.5 supported patients was mean/median 16/11 days vs the program 15/10 days. Post-transplant mean/median total LOS for Impella 5.5 supported patients was 31/25 days vs 28/21 days for the program. There were 3 insertion site hematomas, one CVA and 2 Impella 5.5 induced VT as complications. Survival to transplant was 100%. Results: Impella 5.5 is a safe and efficient way to bridge NYHA Class IV/D, SCAI C/D patients to cardiac transplant, however, it may identify sicker patients as it translates in longer waitlist time as well as post-transplant to discharge time.

CARC19: An Updated Analysis of the Impact of U.S. Heart Transplantation Allocation System Change on LVAD Patients

Background: On 10/18/2018, a substantial U.S. heart transplantation (HT) allocation system change (ASC) became effective, resulting in lower priority for left ventricular assist device (LVAD) patients. While previous preliminary analyses demonstrated worse post-HT survival among LVAD patients between different eras, it remains unclear whether the presence of LVAD independently predicts unfavorable outcomes within the post-ASC period, especially among patients with expected longer wait times. Methods: Two cohorts of adult patients from the UNOS database were included, and their 1-year outcomes were analyzed. The pre-ASC and post-ASC cohorts encompassed patients listed between 10/18/2014 to 10/18/2017 and 10/18/2018 to 10/18/2021, respectively. We excluded patients listed before and transplanted after ASC. Cox regression models and competing risk analysis were performed. Results: 17,923 patients (post-ASC=9,684) were included (26.7% females, mean age of 53.4±12.5 years old). 3,873 had an LVAD (post-ASC=1,958), of which 3,003 underwent HT (post-ASC=1,515). Compared to LVAD patients transplanted in the pre-ASC era, those in the post-ASC era had shorter waitlist time; however, their grafts traveled longer distances with more prolonged ischemic time. After adjustment for potential confounders, LVAD was associated with a lower risk of waitlist mortality in both the pre- and post-ASC periods. Moreover, LVAD was associated with a lower HT rate (HR 0.74, 95% CI 0.70-0.79, p<0.001) and higher one-year post-HT mortality (HR 1.53, 95% CI 1.27-1.84, p<0.001) than those without long-term devices in the post-ASC. Notably, these differences were not observed in the pre-ASC. The association between LVAD and higher post-HT mortality was no longer seen after adjustment for the effect modification by ASC. Conclusions: Our findings suggest that LVAD therapy saves patients’ lives while waiting for HT. However, the ASC brought several changes to practice, which might be associated with increased post-HT mortality observed in patients bridged with LVAD. Further studies are needed to identify the highest-risk subgroups among LVAD patients to promote equity in donor organ allocation.

Lung transplantation despite preformed donor-specific antihuman leukocyte antigen antibodies: a 9-year single-center experience

Pretransplant allosensitization to human leukocyte antigens (HLA) increases the recipient’s waiting list time and mortality in lung transplantation. Rather than waiting for crossmatch-negative donors, since 2013, recipients with preformed donor-specific antiHLA antibodies (pfDSA) have been managed with repeated IgA- and IgM-enriched intravenous immunoglobulin (IgGAM) infusions, usually in combination with plasmapheresis before IgGAM and a single dose of antiCD20 antibody. This retrospective study presents our 9-year experience with patients transplanted with pfDSA. Records of patients transplanted between February 2013 and May 2022 were reviewed. Outcomes were compared between patients with pfDSA and those without any de novo donor-specific antiHLA antibodies. The median follow-up time was 50 months. Of the 1,043 patients who had undergone lung transplantation, 758 (72.7%) did not develop any early donor-specific antiHLA antibodies, and 62 (5.9%) patients exhibited pfDSA. Among the 52 (84%) patients who completed treatment, pfDSA was cleared in 38 (73%). In pfDSA vs control patients and at 8-year follow-up, respectively, graft survival (%) was 75 vs 65 (P = .493) and freedom from chronic lung allograft dysfunction (%) was 63 vs 65 (P = .525). In lung transplantation, crossing the preformed HLA-antibody barrier is safe using a treatment protocol based on IgGAM. Patients with pfDSA have a good 8-year graft survival rate and freedom from chronic lung allograft dysfunction, similar to control patients.

Use of a surgically implanted, nondischargeable, extracorporeal continuous flow circulatory support system as a bridge to heart transplant

Introduction and objectivesWe aimed to describe the clinical outcomes of the use of the CentriMag acute circulatory support system as a bridge to emergency heart transplantation (HTx). MethodsWe conducted a descriptive analysis of the clinical outcomes of consecutive HTx candidates included in a multicenter retrospective registry who were treated with the CentriMag device, configured either for left ventricular support (LVS) or biventricular support (BVS). All patients were listed for high-priority HTx. The study assessed the period 2010 to 2020 and involved 16 transplant centers around Spain. We excluded patients treated with isolated right ventricular support or venoarterial extracorporeal membrane oxygenation without LVS. The primary endpoint was 1-year post-HTx survival. ResultsThe study population comprised 213 emergency HTx candidates bridged on CentriMag LVS and 145 on CentriMag BVS. Overall, 303 (84.6%) patients received a transplant and 53 (14.8%) died without having an organ donor during the index hospitalization. Median time on the device was 15 days, with 66 (18.6%) patients being supported for> 30 days. One-year posttransplant survival was 77.6%. Univariable and multivariable analyses showed no statistically significant differences in pre- or post-HTx survival in patients managed with BVS vs LVS. Patients managed with BVS had higher rates of bleeding, need for transfusion, hemolysis and renal failure than patients managed with LVS, while the latter group showed a higher incidence of ischemic stroke. ConclusionsIn a setting of candidate prioritization with short waiting list times, bridging to HTx with the CentriMag system was feasible and resulted in acceptable on-support and posttransplant outcomes.

Ambulation of Patients With In Situ Femoral Intraaortic Balloon Pump While Awaiting Heart Transplantation.

Ambulation of Patients With In Situ Femoral Intraaortic Balloon Pump While Awaiting Heart Transplantation.

Positive impacts of oral health services provision by a student-led primary care clinic to an Australian rural indigenous community.

This study aimed to determine whether oral health services provision by a dental student clinical outplacement embedded within a Community Controlled Health Service positively impacted a rural Indigenous community and to explore the nature of these benefits. Aggregated and de-identified 2017, 2018 and 2019 student-led clinic services provision data were retrospectively analysed. The change in services mix over time was measured. Rural outplacement clinic operational costs to the university were estimated. Government-funded local public dental clinic waiting list and services provision data were used to identify any student clinic establishment effect. The student-led clinic services mix shifted over time from mainly acute care for toothache towards prevention of disease and tooth restoration, indicating an improvement in patient oral health and correspondingly reduced system costs. Imputed value of 2017-2019 student-led clinic services provision totalled almost AUD$1 million. Government public clinic waiting list times decreased after full establishment of the student-led clinic, indicating decreased pressure on the public system. The Community Controlled Health Service and university partnership improved community oral health care access, its timely delivery and simultaneously provided valuable human capital development from the student training experience. The student-led clinic's targeted Indigenous community showed oral health improvement over time. © 2023 Australian Dental Association.

Impact of waitlist time on post-HSCT survival: a cohort study at a hospital in southern Brazil

IntroductionThe time elapsed from diagnosis to hematopoietic stem cell transplantation (HSCT) is influenced by numerous factors. In Brazil, patients using the public health system are also dependent on the availability of HSCT-specific beds in the hematology ward. Objective and MethodsWe conducted a cohort study of listed patients who underwent allogeneic HSCT at a Brazilian public hospital to investigate the impact of the waitlist time on post-HSCT survival. ResultsThe median time from diagnosis to HSCT was 19 months (IQR, 10 - 43), of which 6 months (IQR, 3 - 9) were spent on the waitlist. The time on the waitlist for HSCT appeared to influence mainly the survival of adult patients (≥ 18 years), with an increasing risk according to this time (RR, 3.53 and 95%CI, 1.81 - 6.88 for > 3 and ≤ 6 months; RR 5.86 and 95%CI, 3.26 - 10.53 for > 6 and ≤ 12 months, and; RR 4.24 and 95%CI, 2.32 - 7.75 for > 12 months). ConclusionPatients who remained on the waitlist for less than 3 months had the highest survival (median survival, 856 days; IQR, 131 - 1607). The risk of reduced survival was about 6-fold higher (95%CI, 2.8 - 11.5) in patients with malignancies.

Heart transplantation from donation after circulatory death: Impact on waitlist time and transplant rate

The effect of using donation after circulatory death (DCD) hearts on waitlist outcomes has not been substantiated. We retrospectively analyzed 184 heart transplant (HT) candidates at our institution from 2019 to 2021. Patients were stratified into 2 observation periods centered on September 12, 2020, when the adult DCD HT program officially began. The primary outcome was a comparison of transplant rate between period 1 (pre-DCD) and period 2 (post-DCD). Secondary outcomes included waitlist time-to-transplant, waitlist mortality rate, independent predictors of incidence of HT, and posttransplant outcomes. A total of 165 HTs (n = 92 in period 1 and n = 73 in period 2) were performed. The median waitlist time-to-transplant decreased from 47.5 to 19 days in periods 1 and 2, respectively (P = .004). The transplant rate increased from 181 per 100 patient-years in period 1 to 579 per 100 patient-years in period 2 (incidence rate ratio, 1.87; 95% CI, 1.04-3.38; P = .038). There were no statistical differences in waitlist mortality rate (P = .566) and 1-year survival (P = .699) between the 2 periods. DCD HTs (n = 36) contributed to 49.3% of overall HT activity in period 2. We concluded that utilization of DCD hearts significantly reduced waitlist time and increased transplant rate. Short-term posttransplant outcomes were comparable between the pre-DCD and post-DCD periods.

Heart retransplant recipients with renal dysfunction benefit from simultaneous heart-kidney transplantation

Given ongoing donor shortages, appropriate patient selection for dual-organ transplantation is critical. We evaluated outcomes of heart retransplant with simultaneous kidney transplant (HRT-KT) vs isolated heart retransplant (HRT) across varying levels of renal dysfunction. The United Network for Organ Sharing database identified 1189 adult patients undergoing heart retransplantation between 2005 and 2020. Recipients undergoing HRT-KT (n=251) were compared to those undergoing HRT (n=938). The primary outcome was 5-year survival; subgroup analyses and multivariable adjustment were performed utilizing the following 3 estimated glomerular filtration (eGFR) groups: <30 ml/min/1.73m2, 30-45 ml/min/1.73m2, and >45 ml/min/1.73m2. HRT-KT recipients were older and had longer waitlist times, longer inter-transplant periods, and lower eGFR levels. HRT-KT recipients were less likely to require pretransplant ventilator (1.2% vs 9.0%, p < 0.001) or ECMO (2.0% vs 8.3%, p < 0.001) support but were more likely to have severe functional limitation (63.4% vs 52.6%, p=0.001). After retransplantation, HRT-KT recipients had less treated acute rejection (5.2% vs 9.3%, p=0.02) and more dialysis requirement (29.1% vs 20.2%, p < 0.001) before discharge. Survival at 5-years was 69.1% after HRT and 80.5% after HRT-KT (p < 0.001). After adjustment, HRT-KT was associated with improved 5-year survival among recipients with eGFR <30 ml/min/1.73m2 (HR:0.42, 95% CI: 0.26-0.67) and 30 to 45 ml/min/1.73m2 (HR:0.29, 95% CI 0.13-0.65), but not among those with eGFR>45 ml/min/1.73sm2 (HR 0.68, 95% CI 0.30-1.54). Simultaneous kidney transplantation is associated with improved survival following heart retransplantation in patients with eGFR <45 ml/min/1.73m2 and should be strongly considered to optimize organ allocation stewardship.

(362) The Impact of Donation after Circulatory Death Heart Transplants on Waitlist Time: A UNOS Analysis

(362) The Impact of Donation after Circulatory Death Heart Transplants on Waitlist Time: A UNOS Analysis

Better Than Ice: Advancing the Technology of Donor Heart Storage With the Paragonix SherpaPak.

Better Than Ice: Advancing the Technology of Donor Heart Storage With the Paragonix SherpaPak.

Association of Body Surface Area With Access to Deceased Donor Liver Transplant and Novel Allocation Policies

Small waitlist candidates are significantly less likely than larger candidates to receive a liver transplant. To investigate the magnitude of the size disparity and test potential policy solutions. A decision analytical model was generated to match liver transplant donors to waitlist candidates based on predefined body surface area (BSA) ratio limits (donor BSA divided by recipient BSA). Participants included adult deceased liver transplant donors and waitlist candidates in the Organ Procurement and Transplantation Network database from June 18, 2013, to March 20, 2020. Data were analyzed from January 2021 to September 2021. Candidates were categorized into 6 groups according to BSA from smallest (group 1) to largest (group 6). Waitlist outcomes were examined. A match run was created for each donor under the current acuity circle liver allocation policy, and the proportion of candidates eligible for a liver based on BSA ratio was calculated. Novel allocation models were then tested. Time on the waitlist, assigned Model for End-Stage Liver Disease (MELD) score, and proportion of patients undergoing a transplant were compared by BSA group. Modeling under the current allocation policies was used to determine baseline access to transplant by group. Simulation of novel allocation policies was performed to examine change in access. There were 41 341 donors (24 842 [60.1%] male and 16 499 [39.9%] female) and 84 201 waitlist candidates (53 724 [63.8%] male and 30 477 [36.2%] female) in the study. The median age of the donors was 42 years (IQR, 28-55) and waitlist candidates, 57 years (IQR, 50-63). Females were overrepresented in the 2 smallest BSA groups (7100 [84.0%] and 7922 [61.1%] in groups 1 and 2, respectively). For each increase in group number, waitlist time decreased (234 days [IQR, 48-700] for group 1 vs 179 days [IQR, 26-503] for group 6; P < .001) and the proportion of the group undergoing transplant likewise improved (3890 [46%] in group 1 vs 4932 [57%] in group 6; P < .001). The smallest 2 groups of candidates were disadvantaged under the current acuity circle allocation model, with 37% and 7.4% fewer livers allocated relative to their proportional representation on the waitlist. Allocation of the smallest 10% of donors (by BSA) to the smallest 15% of candidates overcame this disparity, as did performing split liver transplants. In this study, liver waitlist candidates with the smallest BSAs had a disadvantage due to size. Prioritizing allocation of smaller liver donors to smaller candidates may help overcome this disparity.

Balancing Waitlist Dropout in Pancreas Transplantation

The time a patient spends on the waiting list for a Simultaneous Pancreas-Kidney (SPK) transplant depends on several donor and recipient-specific factors. The average wait-list time for SPK in the United States has been about 1 to 3 years, significantly shorter than the average wait time for kidney-only transplantation. A single-center retrospective analysis of SPK waitlisted candidates was performed to determine the implication of wait-list time on dropout from the wait-list due to death or poor health. We analyzed all deceased donor Simultaneous Pancreas-Kidney wait-listed candidates between Jan 1994 and June 2021. Waitlisted candidates who got transplanted (TG) were compared to those who dropped out from the wait list due to death or poor health (DPHG). In the study period, 297 candidates were waitlisted for SPK transplants. Eight candidates were removed, as transplantation was not needed due to improvement in health while on the waiting list. Fourteen wait-listed candidates transferred to another center were also excluded from the study group. Two hundred and thirty wait-listed candidates were transplanted (TG). Forty-five patients were delisted due to death or poor health (DPHG). The mean body mass index of candidates in TG and DPHG were 25.1 and 24.9, respectively. The mean age at dropout in DPHG was 40.7, similar to the mean age at transplant in TG (39.4). The mean age of diabetes onset was slightly lower in TG (17.4) compared to 20.02 in DPHG. The mean days spent by the candidates on the waitlist in DPHG were significantly higher than those in TG (821 days vs 252 days). Eight of the 45 patients (17.7%) in DPHG had 1 or more organ transplants before listing compared to 1 of 230 patients (0.43%) in TG. Despite low wait times for SPK transplants, increased wait times can account for a dropout from the waitlist due to death or poor health. Centers should exercise caution in wait listing SPK candidates with prior organ transplants.

Study Protocol on Social Return on Investment (SROI) Project of the Surgical Waiting List Management System.

In Andalusia, the right to maximum waiting times for healthcare clashes with the available supply, leading to an increase in demand in the form of waiting lists. To address this situation, the activity of private centers has been created for certain diagnostic tests. The Social Return on Investment (SROI) model evaluates an intervention from an economic and stakeholder perspective. However, there are no studies on the suitability of waiting lists using SROI, which is why it is intended to be studied as a decision-making tool for the clinical and healthcare management of waiting lists. This research protocol is designed to determine the quality of life gained, with the EuroQol-5D-5L questionnaire, and its social assessment, with the specific survey of the SROI method, and, thus, analyze the social return on investment and determine the suitability of the intervention (diagnostic endoscopy activity arranged in a contracted center). After the study, we will know the economic (cost in public health centers and the incremental cost of extraordinary health resources), social (quality of life with health), and environmental scenarios of the concerted activity intervention in order to adjust waiting list times.