A Concentric Neighborhood Solution to Disparity in Liver Access That Contains Current UNOS Districts
A Concentric Neighborhood Solution to Disparity in Liver Access That Contains Current UNOS Districts
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DOI：
10.1097/tp.0000000000001934
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发表时间：
2018-02-01
期刊：
影响因子：
6.2
通讯作者：
Klintmalm, Goran B.
中科院分区：
文献类型：
--
作者：
Mehrotra, Sanjay;Kilambi, Vikram;Klintmalm, Goran B.
背景政策制定者正在考虑改革，以减少肝脏分配的地理差异。公众评论和器官共享联合网络肝脏和肠道委员会表示有兴趣完善社区方法。共享35和共享15策略影响地理差异。方法.我们构建叠加当前11个区域的同心圆社区。使用同心圆的概念，我们为每个捐助者服务区（DSA）构建社区，将400，500或600英里内的所有DSA视为邻居。我们考虑将每个社区限制为10个DSA，并且不使用肝脏供应和需求的指标。我们将共享15政策的终末期肝病模型（MELD）阈值更改为18或20，并应用3点和5点MELD邻近度提升，以增强本地优先级，控制旅行距离并减少差异。我们进行模拟比较当前的分配与社区和共享政策。结果同心社区结构提供了一系列的解决方案，模拟结果表明，它们减少了不同程度的地理差异，年死亡率和飞机旅行距离。调整的参数和政策组合可以导致有益的改善与可接受的移植量损失和减少地理差异和旅行距离。特别是，10-DSA，500英里的社区解决方案与份额35，份额15，和0点MELD提升实现了这一点，同时限制移植体积损失低于10%。结论.目前的11个地区可以通过增加邻近的DSA来系统地调整，以改善地理差异、死亡率和飞机旅行距离。对共享35和共享15策略的修改导致进一步的改进。这些解决办法可以进一步完善，以便实施。
Background. Policymakers are deliberating reforms to reduce geographic disparity in liver allocation. Public comments and the United Network for Organ Sharing Liver and Intestinal Committee have expressed interest in refining the neighborhoods approach. Share 35 and Share 15 policies affect geographic disparity. Methods. We construct concentric neighborhoods superimposing the current 11 regions. Using concepts from concentric circles, we construct neighborhoods for each donor service area (DSA) that consider all DSAs within 400, 500, or 600 miles as neighbors. We consider limiting each neighborhood to 10 DSAs and use no metrics for liver supplies and demands. We change Model for End-Stage Liver Disease (MELD) thresholds for the Share 15 policy to 18 or 20 and apply 3-and 5-point MELD proximity boosts to enhance local priority, control travel distances, and reduce disparity. We conduct simulations comparing current allocation with the neighborhoods and sharing policies. Results. Concentric neighborhoods structures provide an array of solutions where simulation results indicate that they reduce geographic disparity, annual mortalities, and the airplane travel distances by varying degrees. Tuning of the parameters and policy combinations can lead to beneficial improvements with acceptable transplant volume loss and reductions in geographic disparity and travel distance. Particularly, the 10-DSA, 500-mile neighborhood solution with Share 35, Share 15, and 0-point MELD boost achieves such while limiting transplant volume losses to below10%. Conclusions. The current 11 districts can be adapted systematically by adding neighboring DSAs to improve geographic disparity, mortality, and airplane travel distance. Modifications to Share 35 and Share 15 policies result in further improvements. The solutions may be refined further for implementation.