Improving Patient Access to Liver Allografts Through a Mathematically Optimized Continuous Organ Distribution Model.
Improving Patient Access to Liver Allografts Through a Mathematically Optimized Continuous Organ Distribution Model.
复制标题
通过数学优化的连续器官分布模型改善患者获得同种异体肝脏移植的机会。
DOI：
10.1097/tp.0000000000003018
复制
发表时间：
2020
期刊：
影响因子：
6.2
通讯作者：
Lunsford,KeriE
中科院分区：
文献类型：
--
作者：
Panayotova,GuerganaG;Guarrera,JamesV;Lunsford,KeriE
在过去的十年里，美国的肝器官分配政策一直处于移植界争议的前沿。去年，在卫生资源和服务管理局授权改善器官分配的公平性以及由此产生的诉讼之后，争论愈演愈烈。1,2由于需求继续超过器官供应，分配和获得方面的差距变得更加明显。与当前分配实践的共同争论点不仅是器官的可获得性，还包括中心和地区在列表实践中的差异、终末期肝病模型（MELD）例外的应用、移植时受者的医疗灵敏度、边缘供者的利用以及等待时间。3-6综合起来，这些因素深刻地影响着患者移植的可能性，并促使人们寻找解决方案。在这一期的《移植》杂志上，Bertsimas和他的同事发表了他们的文章《平衡肝移植的效率和公平性：器官分配政策评估的权衡曲线》。在这里，他们比较了OPTN/UNOS特设地理委员会目前正在评估的3种分配框架：已批准但有争议的尖锐范围（通过终末期肝病钠[MELD-Na]评分模型进行患者分层的供体医院周围的固定半径）；数学上优化的地理边界（优化的分配区域）；以及持续分配（按医疗紧急程度和与捐赠者的接近程度等因素打分，不受具体地理限制）。使用权衡曲线和标准化的计算机模型进行分配，该小组证明，连续分配系统通过降低受者死亡率和中心之间MELD的可变性，优于前2。无论使用的疾病敏度评分（MELD vs MELD- na）如何，效果都保持不变。此外，先前提出的新型医疗需求评分，即优化的死亡率预测，混合了连续评分的影响，并对所有运输距离的生命挽救效果最大。2,8后一个概念虽然不是本文的主要焦点，但它为数学算法增加了额外的复杂性，需要进一步评估。
Liver organ allocation policy in the United States has been at the forefront of controversy in the transplant community over the past decade. Arguments have intensified in the last year, following the Health Resources and Services Administration mandate to improve equity in organ distribution and the resulting litigations. 1, 2 As need continues to exceed organ availability, the disparities in distribution and access have become more evident. The common points of contention with current allocation practice is not only organ availability, but also center and regional variations in listing practices, application for model of end-stage liver disease (MELD) exceptions, recipient medical acuity at transplant, utilization of marginal donors, and waiting times. 3–6 Combined, these factors profoundly affect a patient’s probability of transplant, and have prompted the search for a solution.In this issue of Transplantation, Bertsimas and colleagues present their article “Balancing efficiency and fairness in liver transplant access: tradeoff curves for the assessment of organ distribution policies.” Here, they compare the 3 distribution frameworks currently under evaluation by the OPTN/UNOS Ad Hoc Geography Committee: the approved, but contested, acuity circles (fixed radii around the donor hospital with patient stratification via model of end-stage liver disease sodium [MELD-Na] score); mathematically optimized geographic boundaries (optimized allocation districts); and continuous distribution (allocation by a score composed of factors such as medical urgency and proximity to donor without specific geographic limits). 7 Using tradeoff curves and a standardized computer model for allocation, the group demonstrates that the continuous distribution system outperforms the former 2 by reducing recipient mortality and MELD variability between centers. 8 The effect is maintained regardless of the disease acuity score used (MELD versus MELD-Na). Furthermore, the previously proposed novel medical need score, the optimized prediction of mortality, compounds the effects of continuous scoring and has the greatest effect on lives saved across all transport distances. 2, 8 This latter concept, while not the primary focus of the article, adds an additional layer of complexity to the mathematical algorithms that bears further evaluation.