Cost Analysis of Liver Acquisition Fees Before and After Acuity Circle Policy Implementation

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Abstract
On February 4, 2020, the Organ Procurement and Transplantation Network/United Network for Organ Sharing (UNOS) implemented a new liver and intestinal organ allocation policy called the acuity circles (AC) framework. The primary concern driving policy change was that the prior allocation framework, Share 35, used donor service areas (DSAs) and regional boundaries for organ allocation, creating geographic disparities in liver transplant.1 Prior to this change, modeling of potential replacement allocation frameworks assessed key metrics, including median Model of End-stage Liver Disease (MELD) score at transplant, number of transplants performed, wait list mortality, posttransplant mortality, transportation time, and percentage of organs flown.1 Considerations in choosing the AC framework included decreased geographic variance of median (range) MELD score at transplant (from 9.97 [8.74-11.90] to 4.33 [3.23-6.27]) and wait list mortality (by approximately 114 deaths per year). The drawbacks were an increase in organ travel time (approximately 12 minutes), percentage of organs flown (from 54.1% to 71.4%), and a manageable increase in costs associated with flight fees.1,2 Contrary to predictions, early analysis found that there were similar differences in both DSA and center-level variance of median MELD score at transplant after AC allocation.3 However, as predicted, the percentage of procurements with a flight-consistent distance substantially increased, and 90 of 112 liver transplant centers in the US saw an increase in the number of flight-consistent distance procurements, suggesting that most centers have also experienced an increase in the transportation costs associated with liver acquisition.

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