Liver and Intestinal Organ Transplantation Committee

1. Liver and Intestinal Organ Transplantation Committee Spring 2014 Update

2. Policy Implementation - Liver Allocation Policy • Share 15/share 35/national share for combined liver-intestine candidates • Implemented June 17, 2013 • Committee monitoring impact of these changes

3. Deceased Donor Liver Transplantsby Era and Status/Allocation Score 9.9% MELD/PELD Exceptions Status or MELD/PELD Score

4. Deceased Donor Liver Transplantsby Era and Share Type DRI: 1.3 CIT: 5.9 hrs Distance: 21 mi M/P (lab): 21 Median Values Shown

5. Median Distance Organ Traveled, Regional Deceased Donor Liver Transplants – Pre vs. Post, By Region Note: Median change in travel distance across regions was +4 miles. Note: Region 6 data not included (1332 miles Pre, 132 miles post) Pre: 12/17/2012 – 6/17/2013 Post: 6/18/2013 – 12/17/2013

6. Summary of National Data • Waiting list deaths reduced by 7% • Increase in MELD/PELD 35+ transplants • Increase in the median MELD/PELD for regional shares

7. Summary of National Data • Increase in the number of LI-IN transplants (9 to 35) • Increase in regional sharing for LI-KI transplant, but no overall increase in the number of transplants • Decrease in the number of discards (238 to 191)

8. Deceased Donor Liver-Intestine Transplantsby Month

9. Policy Implementation – HCC Imaging Policy • October 31, 2013 • Reminders: Documentation, Reporting Templates available on Transplant Pro website http://transplantpro.org/wp-content/uploads/HCC_Worksheet.pdf

10. Recent Public Comment Proposals Adding serum sodium to the MELD score • Public comments: 78.6% supported • Regional votes/comments: 8 in favor, 2 opposed, 1 approved with amendment • ASTS supported, AST opposed • Board did not approve; Committee will resubmit proposal in June 2014

11. Ongoing Committee Initiatives

12. Designing Liver Distribution for Geographic Equity

13. Motivation: Transplant Rates, by OPO MELD 38-39: 18% to 86% Massie/Segev, AJT 2011

14. Motivation: Death Rates, by OPO MELD 38-39: 14% to 82% Massie/Segev, AJT 2011

15. Final rule: “Neither place of residence nor place of listing shall be a major determinant of access to a transplant.”

16. Designing Liver Distribution for Geographic Equity - Recent Activity (Cont’d) • November 2012: Board tasks Committees w/ Disparity Metrics • Liver Committee Metric: Variance of median MELD at transplant across DSAs • March 2013: Liver Committee Key Decisions • Number of districts between 4 and 8 • Minimum number of transplant centers per district: 6 • Waitlist deaths must not be statistically significantly higher • September 2013: Committee reviewed several maps; requested additional analyses

17. Designing Liver Distribution for Geographic Equity • Committee met on 4/1/14 – Reviewed: • Cost Data – Four Components • Pre-transplant care • Transportation • Transplant plus one year follow-up • 2-3 years post-transplant • OPO performance and: Net import, Median MELD, eligible deaths, new listings • Potential impact by ethnicity, gender, pediatric status

18. Designing Liver Distribution for Geographic Equity Committee Meeting, 4/1/14 (Cont’d) • Determine Path Forward for Policy Development • Potential Path Forward: • Concept Document • Committee’s discussions to date • Maps of 4 and 8 “districts” • Survey • Forum • Spring 2015 Public Comment • Will also monitor/assess impacts of Share 35 Staytuned!

19. Other Ongoing Committee Initiatives • Review of MELD/PELD exceptions and RRB practices • Working on guidelines for new standardized exceptions • Training materials for RRBs • National Review Board

20. Questions? • David Mulligan, MD Committee ChairDavid.Mulligan@yale.edu • Name Region # RepresentativeEmail • Ann Harper Committee LiaisonAnn.Harper@unos.org