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Did the New Liver Allocation Policy Affect Waiting List Mortality?

Mary T. Austin, MD, MPH; Benjamin K. Poulose, MD, MPH; Wayne A. Ray, PhD; Patrick G. Arbogast, PhD; Irene D. Feurer, PhD; C. Wright Pinson, MD, MBA

Arch Surg. 2007;142(11):1079-1085.

Objective  To examine the impact of the Model for End-stage Liver Disease (MELD) on waiting list mortality.

Design  Interrupted time series with a nominal inception point of the intervention on February 27, 2002.

Setting  United Network for Organ Sharing Standard Transplant Analysis and Research file data from March 1, 1999, to July 30, 2004.

Participants  All adult candidates on the waiting list for liver transplantation in the United States during the study period.

Intervention  Implementation of the MELD policy.

Main Outcome Measures  Waiting list mortality, waiting time to transplantation, number of new registrants, and posttransplantation survival.

Results  Although no preintervention trend was identified, the policy change was associated with an immediate effect of increasing waiting list mortality by 2.2 deaths per 1000 registrants per month (from approximately 11 to 13 deaths per 1000 registrants per month; 95% confidence interval [CI], 1.1 to 3.4; P = .001) followed by a postintervention decline in waiting list mortality over time (–0.09 death per 1000 registrants per month; 95% CI, –0.16 to –0.03; P <.001). An immediate effect of decreased waiting time was also noted (from approximately 294 to 250 days; –44.4 days; 95% CI, –77.1 to –11.7 days; P <.001), which reached a new, lower postintervention steady state. The intervention had no effect on the number of new registrants listed per month or on 3- and 6-month posttransplantation survival.

Conclusion  After an initial increase in waiting list mortality, the implementation of the MELD-based allocation policy was associated with an overall decline in waiting list mortality and time to transplantation.

Author Affiliations: Departments of Surgery (Drs Austin, Poulose, and Feurer), Preventive Medicine (Drs Ray and Arbogast), and Biostatistics (Drs Arbogast and Feurer) and Division of Hepatobiliary Surgery and Liver Transplantation (Dr Pinson), Vanderbilt University Medical Center, Nashville, Tennessee.

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