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The updated liver allocation policy implemented by the United Network for Organ Sharing (UNOS) in 2020 appears to have increased liver transplant costs for areas with existing healthcare disparities, according to a cross-sectional study.

While post-policy liver transplant volume decreased 8% in centers from low-income states and increased 5.5% in centers from high-income states, hospital costs increased 12% in the low-income areas (P=0.04) and 5.1% in the high-income areas (P=0.64), reported Maria Bernadette Majella Doyle, MD, MBA, of Washington University School of Medicine in St. Louis, and colleagues in .

Import flights for transplants increased 74.6% in low-income states with an associated 93.9% cost increase (P=0.01), while the volume increased 61.6% in high-income states with a 35.8% cost increase (P=0.02).

In addition, dry-run import flights increased 129% in low-income states with a 101% cost increase (P=0.06) compared with a 19% increase in high-income states with an 82.5% cost increase (P=0.44).

"This analysis paints a very concerning picture of the most recent UNOS allocation system," Doyle and colleagues wrote. "Our report raises serious concerns that the current discoverable changes could deprive underserved and disadvantaged populations."

In February 2020, UNOS made changes to their allocation policy to prioritize liver transplant distribution based on patient need, as opposed to location. Looking at the 22 participating centers following this effort, there was a 6% decrease in overall transplant volume, while overall hospital costs increased 10.9%.

From the pre- to post-policy implementation period, local donations after brain death decreased by 54% (median 49 vs 22, P<0.001), while use of imported donations increased by 133% (median 20 vs 46, P=0.003). Imported liver fly-outs increased by 163% (median 19 vs 50, P=0.009), and dry runs increased by 33% (median 3 vs 7, P=0.02). There was a 77% increase in fly-out costs after the policy change (P=0.03).

For centers with decreased volume, liver transplant hospital costs increased 15.7% post-policy change (P=0.048), and there was a 78.7% increase in the number of flight imports, with a 122.4% cost increase (P=0.002).

"The overall cost data are worrisome for the financial health and viability of many transplant centers across the U.S.," Doyle and team wrote, adding that the 10.9% increase in overall hospital costs "resulted in a $46,360,176 increase to the 22 participating centers, despite decreased transplant volumes and an increase in patients admitted for LTs [liver transplants] that did not proceed."

In an , Daniela P. Ladner, MD, MPH, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues noted that the study's low participation rate limited generalizability of the findings.

"First, the study includes 22 centers and 22% of all LTs performed in the U.S., and conclusions for the nation must be drawn carefully," they wrote. "For example, the studied centers reported a 6% LT volume decrease whereas the national LT volume increased, indicating that the participating centers may not be representative."

"Second, the timing of the post-implementation analyses is inopportune, as it was contemporaneous with the emergence of COVID-19, the national lockdown, an overwhelmed healthcare system, sudden changes to many healthcare processes, which affected LT, and increased ," they added.

Furthermore, the immediate comparison before and after the policy change did not allow time for adaptations by the liver transplant centers, they noted.

Lastly, the cutoffs that the researchers used in grouping centers that served racial and ethnic minority populations did not reflect the national proportions, Ladner and team wrote, which "challenges any conclusions drawn regarding populations that are traditionally underserved by healthcare systems."

For this study, Doyle and colleagues invited 68 liver transplant centers (accounting for 76.5% of the national volume) to participate, and received responses from 22 centers, accounting for 18.6% of the national volume. The group reviewed volume and cost data from those centers for 1,948 and 1,837 liver transplants performed in the 12 months before and 12 months after the new UNOS allocation policy, respectively, covering periods from March 4, 2019 to March 4, 2020, and March 5, 2020 to March 5, 2021.

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