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MELD-based allocation of deceased donor livers allows exceptions for patients whose score may not reflect their true mortality risk. We hypothesized that OPOs may differ in exception practices, use of exceptions may be increasing over time, and exception patients may be advantaged relative to other patients. We analyzed longitudinal MELD score, exception, and outcome in 88,981 adult liver candidates as reported to UNOS from2002–2010.Proportion of patients receiving an HCC exception was 0–21.4% at the OPO-level and 11.9–18.8% at the region-level; proportion receiving an exception for other conditions was 0.0%–13.1% (OPO-level) and 3.7%–9.5%% (region-level).HCC exceptions rose over time (10.5% in 2002 vs. 15.5% in 2008, HR=1.09 per year, p<0.001) as did other exceptions (7.0% in 2002 vs. 13.5% in 2008, HR=1.11, p<0.001).In the most recent era of HCC point assignment (since April 2005), both HCC and other exceptions were associated with decreased risk of waitlist mortality compared to non-exception patients with equivalent listing priority (multinomial logistic regression OR=0.47 for HCC, OR=0.43 for other, p<0.001) and increased odds of transplant (OR=1.65 for HCC, OR=1.33 for other, p<0.001).Policy advantages patients with MELD exceptions;differing rates of exceptions by OPO may create, or reflect, geographic inequity.

Severe geographic disparities exist in liver transplantation; for patients with comparable disease severity, 90-day transplant rates range from 18%–86% and death rates range from 14%–82% across donor service areas (DSAs). Broader sharing has been proposed to resolve geographic inequity; however, we hypothesized that the efficacy of broader sharing depends on the geographic partitions used. To determine the potential impact of redistricting on geographic disparity in disease severity at transplantation, we combined existing DSAs into novel regions using mathematical redistricting optimization. Optimized maps and current maps were evaluated using the Liver Simulated Allocation Model. Primary analysis was based on 6700 deceased donors, 28,063 liver transplant candidates, and 242,727 Model of End-Stage Liver Disease (MELD) changes in 2010. Fully regional sharing within the current regional map would paradoxically worsen geographic disparity (variance in MELD at transplantation increases from 11.2 to 13.5, p=0.021), although it would decrease waitlist deaths (from 1368 to 1329, p=0.002). In contrast, regional sharing within an optimized map would significantly reduce geographic disparity (to 7.0, p=0.002) while achieving a larger decrease in waitlist deaths (to 1307, p=0.002). Redistricting optimization, but not broader sharing alone, would reduce geographic disparity in allocation of livers for transplant across the United States.