The new allocation era and policy

Abstract

Since the Department of Health and Human Services (DHHS) issued the Final Rule in 1998 as a guideline for organ transplantation and allocation policies, the lung allocation system has undergone two major changes. The first change came with the implementation of the lung allocation score (LAS) instead of waiting time as the primary determinant for donor lung allocation. The LAS model helped allocate donor lungs based on medical urgency and likelihood of post-transplant success. The LAS has been successful in prioritizing the sickest candidates and reducing waitlist mortality in line with the Final Rule mandates. However, the LAS model did not address geographic variability in donor lung supply and demand, leading to disparities in waiting list survival based on a patient's listing location, which was inconsistent with the Final Rule. In an urgent response to a lawsuit filed by a patient demanding broader geographic access to lungs in November 2017, the second major change in lung allocation occurred when the primary allocation unit for donor lungs expanded from the local donation service area (DSA) to a 250-nautical mile radius around the donor hospital. The Organ Procurement and Transplantation Network has since undergone a review of the current organ allocation systems and has approved a continuous organ distribution framework to guide the creation of a new organ allocation system without rigid geographic borders. In this review, we will describe the history of lung allocation, the changes to the allocation system and their consequences, and the potential future of lung allocation policy in the U.S.

Keywords: Lung allocation; geographic disparities; lung transplantation; policy.

Figure 1

In the pre era there were 2 transplants in the LAS group <20 and 1 transplant in the LAS group 20–30. There was an increase in the number of lung recipients with an LAS in the three highest categories (50–60, 60–70 and 70+) (25). LAS, lung allocation score.

Figure 2

From the figure above it can be seen that there is a decrease in the death rate for candidates in the 60–70 LAS group (25). LAS, lung allocation score.

Figure 3

There is a 58.7% decrease in the number of local transplants. There is an increase in the number of regional transplants with the majority of that increase within the first unit of allocation (250 NM). There is also an overall increase in the number of nationally allocated lung transplants. Figure above shows that 77.3% of lung transplants happen within the first unit of allocation (250 NM) in the post era (25). NM, nautical miles.

Figure 4

Various attributes can be combined to form a composite allocation score that could be weighted evenly or differently. Figure Adapted from Alcorn J. Concept Paper (33).

Figure 5

Demonstrates how a potential composite allocation score combines candidates’ points for each different attribute. The importance of any attribute will determine the maximum amount of points given for it and that will eventually be decided by the OPTN Thoracic Organ Transplantation Committee. Alcorn J. Concept Paper (33). OPTN, Organ Procurement and Transplantation Network.